Emergency Department Overcrowding: Understanding the Factors to Find Corresponding Solutions
Abstract
:1. Introduction
2. Materials and Methods
3. Overcrowding: The Input–Throughput–Output Model
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- Input factors: they are represented by factors determining patient access to the ED. They include the waiting time, the number of patients which arrived in the ED, as well as their severity and complexity. Input factors constitute one of the causes of crowding, but the least important [5,27,28,29,30,31]
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- Throughput factors (internal factors): they are represented by the process time, meaning the time between taking charge of the patient and the outcome (diagnosis and decision: discharge, hospitalization, and transfer). They include all the complementary exams that are performed in the ED (laboratory analysis and imaging). These factors are also affected by the healthcare personnel (in terms of quality of work, shift work, burnout, drop in performance, respect for shifts, and holidays) [3,6].
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- Output factors: they include patients boarding in the ED, availability of hospital beds, and the delay of transport (both internal and external) to leave the ED. The lack of hospital beds appears to be a fundamental cause of overcrowding, but so is the lack of home care. The reduction of beds (which in some realities have decreased by more than 50% in the last 20 years) is a worldwide phenomenon that has led to exit block, as well as to the collapse of the possibility of hospitalizing patients. Considering output factors, it is therefore evident that overcrowding is influenced by the fact that patients who should go to the ward are stationed in the emergency room and must continue to be assisted from a medical point of view [3,5,6].
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- Boarding has a great importance among the causative factors of overcrowding. Boarding is in fact capable of causing a considerable dissipation of resources, which are subtracted from new patients. These resources include space, beds, diagnostic imaging techniques, but also human resources, such as hospital staff. This generates an increase in LOS and negatively affects the output factors, perpetuating the maintenance of overcrowding [23,34,35] A great number of studies provide solutions to limit boarding, although this does not represent the only causative factor of overcrowding, but its resolution would seem mandatory to limit the phenomenon [21].
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- Exit block has a strong impact on overcrowding and is directly connected with the output factors. The solutions that can be promoted to alleviate exit block; however, they must not affect the patients’ outcome [36].
4. Signs of Overcrowding
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- delay in the treatment of patients due to a lack of suitable spaces
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- treatments administered in other spaces of the ED, including corridors
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- prolonged stay of patients in the emergency room at the end of medical treatment, pending transfer to the ward
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- inability to take care of patients transported by ambulance
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- obstruction of the entry and exit routes of the ED.
5. Exit Block: Definition
6. Boarding: Definition
7. The Access Block: Definition
8. Overcrowding: Consequences
9. Overcrowding and COVID Pandemic
10. Overcrowding: Possible Solutions
10.1. Microlevel Strategies
10.2. Macrolevel Strategies
11. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Parameter | Contributing Factors |
---|---|
Input | - emergencies (both medical and surgical) - visit type (both urgent and nonurgent) - ambulance arrivals - number of patients - triage score |
Throughput | - time of processing - patients’ degree of gravity - process of triage and bed placement - bed availability (both in the ED and in the hospital) - staffing (nursing and other healthcare professionals), considering their experience and their training - other services (consultant and ancillary) - degree of boarding |
Output | - hospital occupancy - inpatient bed shortage - transport delay (both internal and external) - staffing ratios - inefficient process of transferring care - inefficient planning of discharging patients - need of higher level of care - inpatients’ degree of gravity - lack of home care (both medical and not) |
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Savioli, G.; Ceresa, I.F.; Gri, N.; Bavestrello Piccini, G.; Longhitano, Y.; Zanza, C.; Piccioni, A.; Esposito, C.; Ricevuti, G.; Bressan, M.A. Emergency Department Overcrowding: Understanding the Factors to Find Corresponding Solutions. J. Pers. Med. 2022, 12, 279. https://doi.org/10.3390/jpm12020279
Savioli G, Ceresa IF, Gri N, Bavestrello Piccini G, Longhitano Y, Zanza C, Piccioni A, Esposito C, Ricevuti G, Bressan MA. Emergency Department Overcrowding: Understanding the Factors to Find Corresponding Solutions. Journal of Personalized Medicine. 2022; 12(2):279. https://doi.org/10.3390/jpm12020279
Chicago/Turabian StyleSavioli, Gabriele, Iride Francesca Ceresa, Nicole Gri, Gaia Bavestrello Piccini, Yaroslava Longhitano, Christian Zanza, Andrea Piccioni, Ciro Esposito, Giovanni Ricevuti, and Maria Antonietta Bressan. 2022. "Emergency Department Overcrowding: Understanding the Factors to Find Corresponding Solutions" Journal of Personalized Medicine 12, no. 2: 279. https://doi.org/10.3390/jpm12020279