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Overcrowding in the emergency department

This article describes why nurses are indispensable in the battle against overcrowding in a Dutch emergency department

M Christien van der Linden PhD
Emergency Department, Medical Centre Haaglanden, the Hague, the Netherlands
Naomi van der Linden PhD 
Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, Australia
One of the most critical issues affecting emergency department (ED) delivery of care worldwide is ED overcrowding.1 Nursing interventions can reduce overcrowding. In this article we will first elaborate on effects and causes of overcrowding, and then discuss various nursing solutions to prevent these problems.
Overcrowding occurs when the demand for emergency care outweighs the accessible resources.Overcrowding is a major barrier to receiving timely emergency care and it contributes to poor quality of care, including prolonged waiting times, prolonged length of stay (LOS), increased suffering for those in pain, poor clinical outcomes, patient dissatisfaction with emergency care, patients leaving without being seen (LWBS), delays in diagnosis, an increase in medical errors, and increased risk of adverse outcomes.2–4
An overcrowded ED also creates problems beyond that department.5 Patients admitted through overcrowded EDs have longer hospital stays,6 leading to less inpatient capacity. When the hospital is at full capacity, ED patients needing admission have to wait for an ambulance to be transferred to other hospitals. When all ED beds are full, EDs go ‘on diversion’ for ambulances: ambulance crews are unable to unload their patients. This reduces resilience and the capacity of ambulance services to respond to calls and increases mortality. 
It is important for hospital and ED management to address overcrowding, not only from a quality point of view, but it also contributes to lost demand for ED services.7 Overcrowding leads to patients LWBS. These walkouts represent significant lost revenue for hospitals. The same is true for ambulance diversions. 
When describing ED overcrowding, its causes are often divided into input, throughput, and output causes.8 Input causes of ED overcrowding include increases in the number of ED presentations, increasingly ageing populations, increasing incidence of chronic conditions, and difficulties accessing primary/general practice and community services. Throughput causes include inadequate numbers of medical staff and nursing staff, waiting times for physician’s examination, and waiting times for blood work and radiological investigations. 
Output causes of ED overcrowding include a lack of appropriate follow-up for discharged patients, inpatient critical care and intensive care bed shortages, extended time needed to transfer patients to other hospitals or nursing homes, and a lack of hospital capacity. In most hospitals, ED overcrowding is a consequence of exit block, where there is insufficient capacity within the hospital.9
Improving patient flow through the ED can reduce overcrowding. However, before interventions to improve patient flow through the ED are instituted, it is critical to identify what the main causes of ED overcrowding are in that particular ED.9 At the Medical Centre Haaglanden Westeinde (MCHW) in the Hague, the Netherlands, nurses and physicians have been struggling with ED overcrowding since 2002. The MCHW is a mixed adult and paediatric inner city hospital, with 52,000 ED visits annually. 
All incoming patients are registered before they undergo triage. During triage, acuity levels are assigned according to the five-level Manchester Triage System.10 The 24-bed ED serves as a regional trauma centre. During peak hours there is a shortage of treatment rooms. Causes of ED overcrowding at the MCHW are apparent in all three phases: an increase in the number of critically ill patients, delays in triage, delays in the clinical decision-making process, delays in diagnostic imaging and laboratory, inpatient boarding and hospital bed shortages.
ED overcrowding is a system-wide problem. Therefore, system-wide solutions are necessary.9 In the last 10 years, several initiatives were introduced at the MCHW to improve the patient flow through the ED.11 In this article, we focus primarily on nursing interventions. 
Photographer: Sanne Donders.
Standing orders
Standing orders are medical orders developed for particular patient conditions or complaints that nursing staff use to carry out specific procedures before physician evaluation.12 At the MCHW ED, standing orders are used at triage. The triage nurses at MCHW are certified emergency nurses (CENs), and these CENs are allowed to request a variety of diagnostic procedures (X-rays, ultrasounds, blood and urine analysis, ECG) and administer analgesia without a physicians’ order. Diagnostic testing at triage is associated with a reduction in ED LOS.12
Emergency nurse practitioners
One of the strategies proposed to improve patient flow and reduce ED overcrowding at the MCHW ED, was to allow trained emergency nurse practitioners (ENPs) to assess and treat patients with non-urgent problems autonomously.11 ENPs are CENs with a Master’s degree in advanced nursing practice working within a defined scope of practice. Local protocols allow ENPs to diagnose and treat patients with a wide range of defined non-life threatening injuries and illnesses, including wounds requiring suturing, simple fractures, and infections of the ear or throat. 
At the MCHW, an extension to the triage system signals whether the patient is eligible for treatment by one of the ENPs. A part of the non-urgent, self-referred patients are redirected from triage directly to the ENP. Approximately 45% of our 150 ED visitors per day are self-referred. Of these self-referrals, 50% are eligible for assessment and treatment by an ENP. Thus, 30–35 patients per day are redirected to the ENP. The ENPs have improved patient flow and decreased mean LOS for patients with minor injuries and minor illnesses.11   
Patient flow coordinator
Patients most affected by ED overcrowding are those who, because of their medical condition, require unplanned admission to hospital. The inability to transfer emergency patients to inpatient beds and the resultant boarding of admitted patients in the ED for long periods, are associated with ED overcrowding. To increase outflow out of the ED, the MCHW opened a flexible acute admission unit (FAAU). 
At the ED, one of the CENs is assigned as a patient flow coordinator to coordinate (amongst other things) admissions during the off-hours. The patient flow coordinator, instead of the admitting consultant, assigns an inpatient bed. The patient flow coordinator is allowed to admit the patient to a FAAU bed when all of the beds in the specialty wards are being used. A before and after interventional study showed a relevant reduction of the number of transfers of admitted patients to other hospitals.13 Thus, flexible bed management combined with a CEN being the patient flow coordinator may be useful in preventing ED overcrowding. 
Internal professional standards
Internal professional standards (IPSs) are locally agreed promises between colleagues and departments. IPS may be time standards (a 30-minute response time for a specialty team to attend the ED) or quality standards (a promise that a consultant will be present at the ED for 12 hours a day, seven days a week).14 At the MCHW, the ED has IPSs with laboratory, radiology, and inpatient units. For example, laboratory results should be available in less than 60 minutes. 
Nurses from inpatient floors have to pick up admitted ED patients within 30 minutes after the phone call that announced the new admission to prevent boarding at the ED. At the ED, the CEN who is assigned as patient flow coordinator coordinates the adherence to the IPSs, for example, the timing of the diagnostic results.
Prevent unnecessary return visits and re-admissions
At the MCH, almost 2500 ED visits per year (5% of total ED visits) are unscheduled within-week return visits. Patients with an urgent triage level, patients presenting during the night shift, patients with abdominal pain, urinary problems, a wound, or local infection are more likely to return unscheduled. Often, worrying about their health is the reason for the patients’ return to the ED.11 Sometimes patients returned to the ED because they did not understand the discharge instructions at their previous ED visit. 
In particular older patients with vision, hearing and cognitive impairments may fail to understand ED discharge information. Older patients are more susceptible to the consequences of failing to understand ED discharge information, facing significant risks including functional decline and increased health service use. In the MCHW, more than half of the patients aged 65 years or older are discharged from the ED after a diagnosis and there is a high ED re-attendance rate among these older patients. 
Providing information to patients about ED diagnosis and plan for follow-up is an important part of ED discharge care, but the time-pressured environment especially during ED overcrowding can present challenges to effectively delivering this information. Patients’ stress and anxiety because of acute illness or injury can cause difficulties in receiving and processing this information. Therefore, ED nurses at MCHW started in 2013 with post-discharge telephone calls within 24 hours. The ED nurses aim to help the elderly with all health questions they have, at the same time decreasing return visits and hospital admissions.
Not only the elderly receive a post-discharge telephone call, but also the patients who left without being seen by a physician and the patients who left against medical advice are called. Telephonic follow-up for walkouts was introduced in 2011. The patients are assisted in obtaining appropriate healthcare access, also preventing unnecessary return visits.
The examples mentioned in this article are only few of the many interventions that exist to improve patient flow at the ED. Potential interventions to improve patient flow through the ED depend on the causes of ED overcrowding at the specific ED.8 ED overcrowding is not a problem that results solely from problems in the ED or one that can be addressed using only ED-based solutions.15
However, because ED nurses are involved at the core of most processes related to patient care and throughput at the ED, they are the people who should understand the causes of ED overcrowding. Seeing the bigger picture and proactively managing patient flow at the ED helps in the struggle against ED overcrowding and improves quality of patient care at the ED.
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