MORTALITY RISK FOR PATIENTS ADMITTED VIA A CROWDED EMERGENCY DEPARTMENT

A Nursing Journal Presented To The Nursing Services Of Ilocos Training and Regional Medical Center San Fernando City, La Union

In Partial Fulfillment of the Requirements for the RN Heals Project Batch IV of the Department of Health

By: Maria Kristina Camille M. Espinosa RN Heals

Date: May 1, 2013

ARTICLE: MORTALITY RISK FOR PATIENTS ADMITTED VIA A CROWDED ED News Author: Jenni Laidman CME Author: Hien T. Nghiem, MD Faculty and Disclosures CME/CE Released: 12/21/2013 Emergency department (ED) crowding is a prevalent healthcare delivery problem both in the United States and internationally. Increasing frequency of ambulance diversion and left-without-being-seen visits have led US EDs to nearing the "breaking point." Overall, the current situation may adversely affect the outcomes of patients requiring hospital admission. The aim of this study by Sun and colleagues was to assess the association of ED crowding with subsequent outcomes in a general population of hospitalized patients. STUDY SYNOPSIS AND PERSPECTIVE Patients admitted to hospitals via crowded EDs may be more likely to die in the hospital than similar patients admitted during slow periods, according to a study published online December 5 in the Annals of Emergency Medicine. Findings also suggest that ED crowding is associated with a slight increase in length of stay and a 1% cost increase. Benjamin C. Sun, MD, MPP, associate professor of emergency medicine, Oregon Health and Science University, Portland, and colleagues studied the admission records from 995,379 ED visits by adults to 187 California acute-care hospitals in 2007, focusing on periods of ED crowding, distinguished by the need to divert ambulances from the hospital. The data were adjusted for case mix, patient demographics, comorbidities, and primary discharge diagnosis. The researchers determined that crowding resulted in 300 inpatient deaths (95% confidence interval [CI], 200 - 500 inpatient deaths), 6200 hospital days (95% CI, 2800 8900 hospital days), and $17 million (95% CI, $11 million - $23 million) in costs. The researchers' primary analysis found a 5% greater odds of inpatient death (95% CI, 2% - 8%) associated with admission via a crowded ED; a fully adjusted sensitivity analysis, however, found that patients admitted via a crowded ED had a 9% (95% CI, 4% 13%) greater risk of dying within 3 days of admission. The primary analysis also found 0.8% increased length of stay (95% CI, 0.5% - 1%) and a 1% increased cost per admission (95% CI, 0.7% - 2%). Hospitals prohibited from diverting ambulances were excluded from this study, as were children's hospitals. Diversions for reasons other than ED saturation, such as the temporary lack of a subspecialty, were excluded from the analysis. In this study, crowding was defined as days within the top quartile of daily ambulance diversion for a specific facility. Potential study limitations include that ambulance diversion "may be an imperfect measure of ED crowding," the authors write. In addition, causality cannot be presumed from this study design; it is possible that "patients with worse outcomes cause ED crowding." Nonetheless, the authors conclude that the "study provides additional evidence that ED crowding is a marker for worse care for all ED patients who might require hospital admission." "Despite mounting evidence that ED crowding is a health delivery problem that reduces access to emergency care, results in worse quality of care, and leads to lower patient satisfaction, there have... been few systematic actions to address the crisis of ED crowding," the authors continue. "Policymakers should heed the recommendations of the Institute of Medicine and address ED crowding as an important public health priority." The

Institute of Medicine described an "overburdened US emergency care system" and outlined potential policy remedies in a report entitled Future of Emergency Care: HospitalBased Emergency Care at the Breaking Point, published in 2006. "ER crowding is dangerous," Dr. Sun said in a journal news release, emphasizing that the problem is "likely to become worse in the future because of the volume, complexity, and acuity of emergency patients." This study was supported by an Emergency Medicine Foundation Health Policy grant and a US federal grant. Dr. Sun was supported by the National Institutes of Health and the University of California, Los Angeles, Older Americans Independence Center. Another author was supported by the National Institutes of Health and the Robert Wood Johnson Foundation Physician Faculty Scholars. Ann Emerg Med. Published online December 5, 2012. STUDY HIGHLIGHTS Investigators conducted a retrospective cohort analysis of patients admitted in 2007 through the EDs of nonfederal, acute-care hospitals in California. The primary outcome was inpatient mortality. Secondary measures included hospital length of stay and costs. ED crowding was established by the proxy measure of ambulance diversion hours on the day of hospital admission. To control for hospital-level confounders of ambulance diversion, periods of high ED crowding were defined as those days within the top quartile of diversion hours for a specific facility. Hierarchic regression models controlled for demographics, time variables, patient comorbidities, primary diagnosis, and hospital fixed effects. Additionally, bootstrap sampling was used to estimate excess outcomes attributable to ED crowding. There were 995,379 ED visits resulting in admission to 187 hospitals. Results of this study revealed that patients who were admitted on days with high ED crowding experienced 5% greater odds of inpatient death (95% CI, 2% - 8%), 0.8% longer hospital length of stay (95% CI, 0.5% - 1%), and 1% increased costs per admission (95% CI, 0.7% - 2%). Excess outcomes attributable to periods of high ED crowding included 300 inpatient deaths (95% CI, 200 - 500 inpatient deaths), 6200 hospital days (95% CI, 2800 - 8900 hospital days), and $17 million (95% CI, $11 - $23 million) in costs. Additional analyses revealed that high ED crowding was associated with 9% (95% CI, 4% 13%) greater odds of inhospital death within 3 days. Lastly, admission on days with greater than 5 ambulance diversion hours vs admission on days with 0 diversion hours was associated with 6% increased odds of inpatient death (95% CI, 2% - 10%). This study included the following limitations: Ambulance diversion hours may not be an accurate measure of ED crowding. Findings may be subject to unmeasured confounding factors. The observational design cannot exclude the possibility of endogeneity or reverse causation. Findings may be mediated through inpatient vs ED crowding. Findings may not be generalized to other settings and countries. SUMMARY: ED crowding may reduce access through prolonged waiting times or through increased time to care as a result of longer ambulance transport after diversionA large literature has demonstrated the negative effect of ED crowding on throughput, including delays in the treatment of myocardial infarction, pneumonia, and painful conditions. Finally, output focuses on the transfer or discharge of patients from the ED. A common barrier to output is high inpatient occupancy, resulting in patients boarding in the ED while waiting for an available hospital bed. Prolonged boarding times may delay definitive testing and increase short-term mortality, length of stay, and associated costs. Continuity of care in the ED may be compromised by frequent nursing and physician shift changes,

and ED priority on evaluating new patients may divert attention from ongoing care of boarded patients. Crowding in EDs poses educational challenges, but with some creativity, flexibility, and desire to make the most of a challenging situation, educational excellence is an achievable goal. Emergency department crowding is one of the leading problems facing emergency physicians, nurses, and their patients, in most developed countries. It has been proposed that emergency department crowding is the equilibrium state of the current health care system. While this may be so, it is not safe; there is a large body of evidence that patients are harmed in crowded emergency departments. Crowded departments threaten delivery of timely care. Delays to analgesia, antibiotic therapy, and thrombolysis or percutaneous coronary intervention are all well described. Compliance with other recognized care standards is reduced. Regular medications are omitted in elderly frail patients. One author has estimated that more people die avoidably as the result of crowding in New Zealand than in road traffic collisions. Similar opinions have been expressed by Australian authors, though the weakness of the underlying evidence is acknowledged. Patients with more complex needs are more likely to board in the emergency department. Studies have shown that frail, elderly patients and critically ill patients are more likely to spend disproportionate time boarding in the emergency department. Crowding also impairs dignity, privacy, and completeness of care. A crowded emergency department creates problems beyond that department. Ambulance crews are unable to unload their patient. This reduces resilience and the capacity of prehospital services to respond to calls. Patients harmed by crowding in an emergency department continue to suffer after they have been admitted. There is some evidence that patients admitted through crowded emergency departments have longer hospital stay. Emergency patients are also more likely to be admitted when the emergency department is crowded. This is most likely because the emergency departments ability to safely discharge patients is compromised. Clinical implications includes manifestations of ED crowding include increasing frequency of ambulance diversion and left-without-being-seen visits. Periods of high ED crowding were associated with increased inpatient mortality rates and modest increases in hospital length of stay and costs for admitted patients.

REACTIONS:
IMPLICATIONS TO NURSING EDUCATION: Patient education is a key component for the management of many acute and chronic conditions. Presentation to the emergency department (ED) may offer an opportunity for patient education. Patient education is provided in a variety of settings across the continuum of care. In ambulatory care and outpatient settings, health education has been shown to improve outcomes for patients.

EDs have become major access points for healthcare in many jurisdictions, where a large proportion of visits are for non-urgent problems. In part, presentation to the ED for non-urgent conditions is due to poor access to primary care and for some, it may be the only point of contact with the healthcare system. Because of this shift in healthcare utilization, there is an increasing need to consider delivery of patient education and counseling in EDs. However, there are many barriers to providing adequate patient education in this setting. Overcrowded conditions and the length of time required to provide the necessary information may affect ED staffs' ability to provide teaching. While some believe that the ED is not an appropriate venue for education, others believe that it offers a unique "teachable moment" during which time patients may be motivated to learn from healthcare providers. In some cases, moderate stress enhances an individual's ability to learn, particularly if the information provided is not too complex. Considering all opportunities for patient counseling and self-management support including the ED seems prudent in today's healthcare environment.

ER workers are at particular risk for exposure to blood, and bloodborne pathogens because of the immediate, life-threatening nature of emergency treatment. Practicing universal precautions when dealing with blood and other potentially infectious materials should always be observe by ER nurses. Nurses should wear appropriate personal protective equipment such as gloves, gowns and face masks, when in contact to blood or to infectious patients. Hand washing is the most convenient and primary prevention of spreading microorganisms and it should be properly done by ER nurses. Teaching patients by doing the appropriate steps of hand washing is simply the best thing any nurses can make when conducting health teachings to their patients

IMPLICATIONS TO NURSING PROFESSION:

Hospital emergency departments are where life-and-death decisions are made every day. Communities and patients rely on them to save lives. But the crisis of hospital ED crowding threatens patient safety and community trust.

Patients who check into a hospital's emergency room (ER) often experience long wait times in an emergency room waiting area. These wait times are due to the triage process that is requisite to hospital admission, patient "boarding" (waiting for a bed), a shortage of on-call physicians and the pile-up of emergency patients due to local accidents and disasters. As ER wait times can lead to delayed treatment of patients who require immediate medical care, hospitals must focus efforts on reducing the amount of time patients must spend in the waiting area.

Improving triage is one strategy for enhancing overall ED flow. To help EDs improve triage of patients. Deciding which patients get treated first is the critical task of the triage nurse. Within a few minutes, the nurse must size up how severely ill or injured a patient is and get him to the right place for care, whether it is a fast-track area for less ill patients or an ED bed for immediate lifesaving interventions. The triage tool stratifies patients into five groups from 1 (most urgent) to 5 (least urgent) based on their severity of illness and need for resources such as tests or treatments. This approach accurately identifies patients who need to be seen immediately and those who can safely wait to be seen. Severity is determined by stability of vital functions and potential for life, limb, or organ threat. Crowding also harms staff. There are associations with absenteeism, staff sickness, and burnout. These result in experienced staff leaving and more junior staff, or agency staff delivering an increasingly busy and inefficient service. An emergency nurse is a registered nurse who provides initial care and treatment to emergency or trauma patients, those who are severely ill or injured and need immediate attention. The job outlook for emergency nurses is good and specialization is usually not required, but their responsibilities are rigorous. They frequently deal with lifethreatening conditions. Most commonly working in a hospital's emergency department, emergency nurses must be able to think and act quickly to assess and treat patients who suffer from a wide range of injuries or illnesses. Using both general and specific health care knowledge, the emergency nurse is the first person to see and treat these patients. These nurses provide initial assessments that are passed on to emergency room doctors and other physicians. These RNs treat a large number of cases each day, and they must be ready for patients of any age with any condition. For this reason specialization is rare and more

general knowledge is valued. There are, however, some specialization areas for emergency RNs, including pediatrics, geriatrics and trauma. It is the responsibility of the emergency nurse to provide care and make accurate assessments in high-stress and possibly life-threatening situations. Emergency nurses must possess the emotional stability to cope with these conditions and remain calm and sympathetic as they perform their duties.

IMPLICATIONS TO NURSING RESEARCH:

A crowded emergency department waiting room is more than unpleasant: New research suggests its a serious hazard to your health. Researchers recently looked at the difference in outcomes of patients who entered California hospitals through the emergency department in 2007. They looked at patients who visited the emergency department when it was saturated, working at capacity and diverting ambulances elsewhere, and those who visited at less crowded times. There arent many differences in the types of patients who visit the emergency department when its crowded or when its empty. Of those who came in to a saturated emergency room, 10.3 percent had congestive heart failure, compared to 10.4 percent of those arriving during less crowded hours. Simply counting the number of patients who leave before treatment is simple, but ignores the complexity of crowding. Crowding is caused by multiple factors. These can be best thought of in terms of input, throughput, and output. Input factors include not only the volume, but also the acuity and type of patients. The reasons for this are not well understood. Primary care has also seen a substantial increase in activity in the same time period. Older people, a growing group, typically require disproportionate care [18]. Patients with mental illness and critical care patients require extensive emergency department care. A small increase in any of these groups has a knock-on effect. Inappropriate attenders, a judgemental term for patients, who could receive medical care elsewhere, do not significantly contribute to crowding. Input problems need not cause crowding if the rest of the emergency admission and discharge process works well. Throughput factors refer to activities within the emergency department that can hinder patient flow. Emergency departments are extremely complex systems and almost any activity can lead to crowding. Poor emergency department design, which does not support flow, contributes to crowding. A linearly designed emergency department, where cubicles flank a long straight corridor, is probably most efficient. Having adequate physical space helps. However, merely increasing cubicle spaces does not reduce crowding if processes within the department and in the main hospital are not improved. Delays with diagnostic imaging and laboratory results may contribute to crowding. Inadequate numbers of medical and nursing staff may also be a factor. Increasingly stringent care standards for conditions such as sepsis, transient ischaemic attack and stroke have increased the workload of emergency departments. Patient and professional expectations are higher. Analysis of the separate components of the time patients spend in the emergency department has shown that waiting comprises 5163% of total patient turnaround time. Major components are time away for radiological investigations, waiting time for the first physicians examination, and waiting time for blood work. Output factors are the main cause of emergency department crowding. Lack of inpatient beds is the single most important cause of crowding. A lack of critical care beds leads to high acuity patients remaining in the emergency department. Worldwide the trend has been to reduce inpatient bed capacity. Quality standards such as single sex compliance in the NHS, and infection control policies, have further contributed, though they are difficult to quantify. Emergency department crowding is an increasingly recognised problem across the world. While the evidence is clear of the harms, future work needs to systematically evaluate interventions and guide evidence-based policy.