Overcrowding in the Emergency Department

PICOT

Does performing a medical screening examination (MSE) in the triage and POCT in the ED compared to not conducting an MSE lead to less waiting time within the emergency department?

P- Patients using Emergency Department for non-emergent complaints Overcrowding in the Emergency Department.

I- Medical screening examination (MSE) and POCT in ED

C- Not performing medical screening examination (MSE) and lack of POCT in ED

O- Less waiting time

Literature Review

According to Erenler et al (2014), the emergency department is among the most overcrowded units in a healthcare system. The overcrowding leads to delays in service delivery and this might have negative consequences for the patients. This is supported by Morley et al (2018) who explains that overcrowding with EDs leads to poor quality of care as manifested by aspects such as prolonged waiting times, delayed treatment, poor prioritization, fatalities, increased costs, as well as patients’ dissatisfaction. Erenler et al (2014) further add that overcrowding in the emergency department generates negative effects and put the whole organization at risk, in addition to contributing to long waiting times. The long waiting times cause patient dissatisfaction, prolonged pain and unnecessary suffering to the patients. A study conducted by Morley et al (2018) found out that lengthy waiting time in the ED leads to some patients leaving without being attended. Additionally, the overcrowding in the busy practice environment within the ED can be attributed to staff burnout as well as high turnover rates.

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However, as Pines & Bernstein (2015) explain a high number of patients present to the emergency department with non-acute problem. Some of the reasons why some patients use the department for non-acute conditions encompass convenience or lack of awareness. Majority of patients perceive the emergency department as a fallback for the incapacity of the healthcare system to address their healthcare needs. As a result, there are many patients who use the ED for conditions that are not emergencies and this significantly contributes to the overcrowding.

Morley et al (2018) opine that having healthcare providers in the triage is an innovative strategy to improve flow in the ED and increase patient satisfaction. Jarvis (2016) suggests that triage can be used in stratification of patient presentations as well as prioritizing them; therefore, this can ensure that only patients with emergent issues precede to the ED. Currently, triage nurse is used in patient stratification and has been shown to assist in speedy diagnosis, reduced waiting times, as well as speedy patient throughput within the emergency department. Physician-led triage has also been proposed as having the potential to improve flow in the ED. This is supported by Morley et al (2018) who established that having a doctor in triage is effective in reducing overcrowding in the ED. Jarvis (2016) further explains that Point-of-care testing (POCT) can be effective in reducing ED overcrowding. This is because POCT facilitates rapid findings for the ordered investigations and hence accelerates diagnosis within the ED. Various studies have also demonstrated that using POCT in the ED reduces turnaround times in all investigations. A randomized controlled study was conducted in the UL to assess the impact of POCT within the ED for patients with cardiac problems. This study illustrated a discharge rate of 20% higher in patients who had their laboratory tests examined by POCT. These findings are supported by Rooney & Schilling (2014) who explain that overcrowding in the ED is a multifactorial aspect and hence diagnostic protocols can improve patient flow; therefore, POCT presents s strategy whereby clinical decision making and patient management can be accelerated to offset the adverse impact of overcrowding within the ED. When utilized efficiently and appropriately, POCT has been demonstrated to decrease delays in initiating treatment for critically sick patients, improve health outcomes, increase discharge rate, as well as reduce length of stay (Rooney & Schilling, 2014) Overcrowding in the Emergency Department.

However, Pines & Bernstein (2015) takes a different perspective and suggests that solutions to overcrowding should target the causes in the ED. Accordingly; a multidisciplinary approach should be used in addressing overcrowding in the ED since most of the contributing factors to the overcrowding take place outside the emergency department. This is because improving internal efficiency of the ED does not have a significant effect on overcrowding since most of the causes of overcrowding are deeply ingrained within the inpatient capacity as well as lack of adequate hospital resources. Therefore, to adequately address overcrowding in the ED, it would be important to address external causes such as lack of adequate staff in the ED and the hospitals’ incapacity. Therefore, the most effective strategies to dealing with the overcrowding should include increasing number of staff, increase bed-capacity within the ED, as well as provision of adequate supplies and resources within the ED (Yarmohammadian, et al, 2017).

References

Erenler A, Akbulut S, Guzel M, Halil C, Alev K, Burcu T & Baydin A. (2014). Reasons for Overcrowding in the Emergency Department: Experiences and Suggestions of an Education and Research Hospital. Turk J Emerg Med. 14(2): 59–63.

Jarvis P. (2016). Improving emergency department patient flow. Clin Exp Emerg Med. 3(2): 63–68.

Morley C, Unwin M, Peterson GM, Stankovich J, Kinsman L. (2018) Emergency department crowding: A systematic review of causes, consequences and solutions. PLoS ONE. 13(8): e020331.

Rooney K & Schilling U. (2014). Point-of-care testing in the overcrowded emergency department – can it make a difference? Critical Care.18 (692).

Yarmohammadian M, Rezaei F, Abbas H & Nahid T. (2017). Overcrowding in emergency departments: A review of strategies to decrease future challenges. J Res Med Sci. 22(23).

Pines J & Bernstein S. (2015). Solving the worldwide emergency department crowding problem – what can we learn from an Israeli ED? Israel Journal of Health Policy Research.4 (52) Overcrowding in the Emergency Department.

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