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Effectiveness of Emergency Medicine Wards in reducing length of stay and overcrowding in emergency departments
International Emergency Nursing 22 (2014) 116–120
Contents lists available at ScienceDirect
International Emergency Nursing journal homepage: www.elsevier.com/locate/aaen
Effectiveness of Emergency Medicine Wards in reducing length of stay and overcrowding in emergency departments Shuk Man Lo RN BSN MPH FHKAN (Emergency) a,⇑, Kenny Tze Ying Choi RN BSN FHKAN (Emergency), Registered Nurse b, Eliza Mi Ling Wong RN BHS MHA PhD, Assistant Professor c, Larry Lap Yip Lee MRCSEd FHKAM (Emergency Medicine), Associate Consultant a, Richard Sai Dat Yeung FCEM FHKAM (Emergency Medicine), Consultant a, Jimmy Tak Shing Chan FCEM FHKAM (Emergency Medicine), Chief of Service a, Sek Ying Chair RN MBA PhD, Professor c a
Emergency Department, Alice Ho Miu Ling Nethersole Hospital, Tai Po, New Territories, Hong Kong Special Administrative Region Emergency Department, Tuen Mun Hospital, New Territories West, Hong Kong Special Administrative Region c The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region b
a r t i c l e
i n f o
Article history: Received 24 May 2013 Received in revised form 14 August 2013 Accepted 17 August 2013
Keywords: Emergency Medicine Ward Overcrowding Effectiveness Emergency Department Length of stay Service development
a b s t r a c t Objective: This study aims to evaluate the effectiveness of an Emergency Medicine Ward (EMW) in reducing the length of stay (LOS) in the emergency department, length of hospitalization, emergency medical admission rate, and the hospital bed occupancy rate. Methods: This study is a cross-sectional, observational study with a retrospective, quantitative record review conducted at the EMW of a regional acute hospital in Hong Kong from January 2009 to June 2009. Results: During the study, a retrospective audit was conducted on 1834 patient records. The five main groups of patients admitted into EMW suffered from cardiac disease (26.5%), pneumonia (19.6%), dizziness (16.2%), Chronic Obstructive Pulmonary Disease (12.3%), and gastroenteritis (7.9%). The mean LOS in the EMW was 1.27 days (SD = 0.59). The average emergency medical admission rate within the six-month period was significantly reduced relative to that before the EMW became operational (January 2008 to June 2008). Clinically, the medical in-patient bed occupancy was significantly reduced by 6.2%. The average LOS during in-patient hospitalization after the EMW was established decreased to 4.13 days from the previous length of 5.16 days. Conclusions: EMWs effectively reduce both the LOS during in-patient hospitalization and the avoidable medical admission rate. Ó 2013 Elsevier Ltd. All rights reserved.
Introduction The healthcare system is increasingly pressured to accommodate the increasing demand for healthcare services. Aging population, increasing hospitalization, and shortage in hospital beds are regarded as public, economic, and healthcare concerns. Long wait times for hospital bed availability and overcrowding in emergency departments (EDs) are commonly observed. These occurrences may delay patient’s treatment and compromise the quality of healthcare provided to patients (Derlet and Richards, 2000). ED overcrowding is defined as ‘‘the situation where ED function is impeded primarily because the number of patients waiting ⇑ Corresponding author. Address: Alice Ho Miu Ling Nethersole Hospital, Accident and Emergency Department, 11 Chuen On Road, Tai Po, New Territories, Hong Kong Special Administrative Region. Tel.: +852 26892145; fax: +852 26671205. E-mail address: [email protected] (S.M. Lo). 1755-599X/$ - see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ienj.2013.08.003
to be seen, undergoing assessment and treatment, or waiting for departure exceeds either the physical or staffing capacity of the ED’’ (Australasian College for Emergency Medicine, p. 340). ED overcrowding is identified as multi-factorial and complex (Hoot and Aronsky, 2008) and commonly associated with extended wait times, lack of ED staff (Schneider et al., 2003), increased patient acuity (Jayaprakash et al., 2009), hospital bed occupancy (Cooke et al., 2004), as well as insufficient physical environment and access block (Forero et al., 2010). Access block is referred to as ‘‘the situations where patients in the ED requiring inpatient care are unable to gain access to appropriate hospital beds within a reasonable time frame’’ (p. 340) (Australasian College for Emergency Medicine, 2002). Access block and consequent ED overcrowding exert influence on the quality of emergency care (Richardson, 2001), patient morbidity and mortality (Sprivulis et al., 2006), as well as staff and patient satisfaction (Derlet and Richards, 2000).
S.M. Lo et al. / International Emergency Nursing 22 (2014) 116–120
In response to these problems, strategies for coping with the increasing demand for hospital beds have been implemented. Chest pain observation units (Martinez et al., 2001), rapid assessment zones (Bullard et al., 2012), and clinical decision units (Roberts et al., 2010) have evolved to meet the demands of ED in the US, Canada, and the UK. They provide alternatives to the management of specific disease groups of patients in overcoming access block and consequent ED overcrowding. In Hong Kong, Emergency Medicine Wards (EMWs) (similar to short-stay unit) have emerged because of their potential to reduce access block and streamline appropriate health service delivery.
Background EMWs were developed in 2008. To date, 68% of EDs in Hong Kong offer EMW service. EMWs aim to reduce avoidable hospital medical admissions and consequent ED overcrowding, as well as reduce costs. Despite variations in EMWs, these EMWs share a similar mission and are commonly governed by the Hospital Authority (HA). The EMWs provide tailor-made services for the region population under study. First, the care was protocol-driven to a specific group of patients with reference to individual departmental policies. The protocols used [i.e. chest pain, hypertension (HT), and Chronic Obstructive Pulmonary Disease (COPD) protocols] were derived from international guidelines and evidence and then modified to suit the local setting and culture. We sought the approval of a panel of medical consultants, nurse managers, and nurse specialists in emergency medicine. The patient care service also encouraged inter-departmental and inter-disciplinary collaboration by an inpatient consultation and referral system, such as community nurse service and a geriatric team. Second, ward rounds were conducted by emergency specialists who perform four to six rounds per day. With this approach, all patients were treated promptly (Hospital Authority, 2008). In this acute hospital in the region, the EMW manages almost all medical patients, except those requiring airborne precautions, suffering from renal failure and on continuous ambulatory peritoneal dialysis, and critically ill. Patients are expected to be in a stable condition and discharged within 48 h. If the medical condition requires longer hospitalization and specialty care, the patient is transferred to an appropriate medical unit. The process ultimately aims to improve the quality of medical care through extended observation and multi-disciplinary care and simultaneously reduce inappropriate hospital admission and healthcare costs. EMWs provide alternative in-patient beds for subacute patients (Hospital Authority, 2008). Systematic reviews have been conducted on the effectiveness of all similar types of short-stay, observation, and subacute medical units. Numerous studies have shown that these units can effectively reduce mortality, length of stay (LOS), and access block, as well as improve staff and patient satisfaction (Cooke et al., 2003; Daly et al., 2003; Scott et al., 2009). However, studies have rarely been conducted in Asian countries. In Hong Kong, the future development of EMWs remains uncertain because of the emergence of different EMW models. The effectiveness of existing systems in each hospital must first be ascertained prior to the conclusive identification of the model that works effectively. Cost-effective resource allocation for EMW can be determined subsequently. The overall purpose of the present study is to assess the role, effectiveness, and future direction of EMWs in addressing the global problem of hospital bed availability (access block) and the increasing demand for quality service, considering that EMWs have been operational for four years. This study aims to evaluate the effectiveness of EMWs in terms of LOS in ED and hospitalization, medical in-patient admission rate, and bed occupancy.
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Methods Study design and setting This study is a cross-sectional, observational study involving a quantitative, retrospective review of the ED records of all EMW patients during the study period. This study was conducted with the approval of the joint Chinese University of Hong Kong–New Territories East Cluster clinical research ethical committee. The EMW is located in a regional government acute care hospital with 583 beds, which serves approximately 300,000 people in the local district. According to the internal statistics of ED, the average daily ED attendance in 2008 was nearly 327, and the medical admission rate constituted 55.31% of all emergency admissions. Moreover, the overall in-patient bed occupancy rate reached 98.8%. The 26-bed unit EMW was established in December 2008. Data collection The data collection periods were divided into two parts. The first part included the EMW data collected from January to June 2009; the ED records of all adult patients were retrieved during this period. Adult patients who were provided care for their medical illnesses at the ED and then admitted to the EMW for continuity of care were included. Meanwhile, part two included the data of a group of patients with similar diseases prior to the establishment of the EMW (i.e., from January to June 2008). All data were retrieved retrospectively through the Clinical Management System, a Hong Kong-wide computerized patient management system of the HA. Established in 1990, HA is a statutory body responsible for managing public hospitals in Hong Kong. Fig. 1 illustrates the conceptual framework for analyzing the effectiveness of EMW. Outcome measurement Outcome measurements included the ED first attendance, triage category, LOS of in-patient hospitalization, LOS in ED, medical inpatient admission number, and bed occupancy. These outcomes with and without EMW were compared. Data analysis Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 20.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were presented to summarize the demographic and clinical data. The data consisted of age, gender, provisional diagnosis, triage category, past health, final disposal from the EMW, and LOS in the EMW and the ED. T-tests were used to measure the differences in LOS during in-patient hospitalization, medical in-patient admission, and bed occupancy before and after the establishment of the EMW. The level of significance was set at 5% in all comparisons. Results From January to June 2009, the average ED first attendance was calculated as 319 patients per day, with a total of 1834 EMW admissions. Among the eligible EMW patients (N = 1834), 56% consisted of male patients. Most patients were elderly, with a mean age of 69.36 (SD = 18.29). Nearly 85% of the patients suffer from significant comorbidities, such as hypertension, diabetes mellitus, heart disease, and COPD. The five main disease categories were cardiac disease (26.5%; N = 486), pneumonia (19.6%; N = 359), dizziness (16.2%; N = 297), COPD (12.3%; N = 226), and gastroenteritis (7.9%; N = 145) (Table 1). Most of these patients were triaged in
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ED patients require hospitalization for continuity of care Screening by Emergency Specialists
EMW 20 medical beds + 6 post-operative beds Operated by emergency specialists and nurses
Patient disposition 1. 2. 3.
Admit medical unit Admit EMW if meet the criteria #
Discharge home/old aged home directly Transfer to convalescent hospital Transfer to medical unit for continuity of care
Effectiveness
Notes: # EMW Admission criteria All medical cases are admitted to EMW except: a) Patient requiring airborne precaution; b) Renal failure patient on CAPD; and c) Patient with critical clinical condition
Length of stay in Emergency Department Length of stay during in-patient hospitalization Emergency Medical admission rate Medical in-patient bed occupancy
Expected Outcome Alleviate Emergency Department overcrowding environment And reduce LOS during in-patient hospitalization
Fig. 1. Conceptual framework on the effectiveness of Emergency Medicine Ward (EMW).
Table 1 Reason for admission into EMW. Reasons of admission into EMW Cardiac problem (hypertension, coronary heart disease, arrhythmia) Pneumonia/fever Dizziness/neurological problem COPD Gastroenteritis Diabetes mellitus Decrease general condition Urinary tract infection Post convulsion Others (gout, buttock abscess, osteoarthritis, depression) Total
Frequency (N)
Percent (%)
486
26.5
359 297 226 144 88 86 33 4 110
19.6 16.2 12.3 7.9 4.8 4.7 1.8 0.2 6.0
1834
100.0
Note: EMW = Emergency Medicine Ward; COPD = Chronic Obstructive Pulmonary Disease.
Table 2 Patient disposition in EMW. Final disposal from EMW
Frequency (%)
Discharge home/old aged home Transfer to medical unit of AHNH Transfer to convalescent hospital Transfer to medical unit, then convalescent hospital
1095 (59.7%) 504 (27.5%) 198 (10.8%) 37 (2%)
Total
1834 (100%)
Note: EMW = Emergency Medicine Ward.
Category 3 (52.9%) and Category 4 (43.9%). Their mean LOS in ED before and after admission to the EMW was 4.46 (SD 3.086) and 1.27 days (SD 0.59), respectively. With regard to their final discharge destination, 59.7% of the patients were discharged directly from the EMW (Table 2). These patients comprised only 1.4% of the emergency re-attendance rate within 48 h. Outcome measure (effectiveness) Table 3 summarizes the comparison of outcomes for the six months before the EMW (January to June 2008). No significant difference in the emergency first attendance and triage categories was indicated between these two periods. The average emergency medical admission rate was significantly reduced (mean difference: 14.4%, 95% CI: 12.6–16.2). Moreover, the medical in-patient
bed occupancy was significantly reduced by 6.2% (p = 0.006). The average number of patients admitted in the medical unit per month was reduced by 187. A significant difference was also indicated in the LOS of in-patient hospitalization before and after the establishment of the EMW, with a mean LOS of 4.13 ± 6.01 days in contrast to 5.16 ± 4.97 days (95% CI: 0.85–1.21). No significant difference was found in the mean LOS in ED. Discussion This study evaluated the function of EMW in relieving ED overcrowding during the winter surge period. In the hospital under study, the EMW mainly manages medical conditions such as cardiac problems (Hypertension and coronary heart disease), pneumonia, Chronic Obstructive Pulmonary Disease and dizziness. Similar to those other countries, medical patients contribute to the high admission rate for in-patient hospitalization. A national survey of observation units in the US revealed that 96.9% of patients suffer from medical illnesses such as chest pain/cardiac disease (Mace et al., 2003). The present study revealed that older adults with highly complex medical problems comprise the main group of patients admitted into EMW. Half of the EMW patients were in Category 3 (those with urgent clinical conditions) with increased severity of illness. Prior to the EMW operation, these patients were admitted into medical units, thereby increasing medical bed occupancy. Total medical in-patient admission was reduced significantly by 187 admissions monthly and the average emergency medical admission rate decreased by 15% relative to those prior to the EMW operation. This finding suggests that EMW shares the workload of medical units and contributes significantly to the decrease in total medical admission and admission rate. In the UK, the clinical decision unit (which is similar to EMW) also functions successfully as an alternative to emergency hospitalization (Roberts et al., 2010). In addition, the mean LOS in the EMW was only 1.27 days, and 60% of these patients were discharged directly from the EMW. This result indicates that a specific group of medical patients can be treated and managed efficiently by emergency specialists and nurses, whether they are in the EMW or an ED observation unit (EDOU). Gonnah et al. (2008) observed that EDOUs can effectively reduce the medical admission rate, especially for patients with chest pain (52.7%) and bronchial asthma (49.2%). In addition, Juan et al. (2006) reported that patients with COPD and were admitted into an ED short-stay unit showed a significantly lower mean LOS and mortality than those admitted into an in-patient unit. These
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S.M. Lo et al. / International Emergency Nursing 22 (2014) 116–120 Table 3 Outcome measure before and after the operation of EMW. Outcome
Before operation of EMW (January 2008 to June 2008)
After operation of EMW (January 2009 to June 2009)
Mean difference
P value
Monthly ED first attendance (N) Triage category 1–3 (%) Triage category 4–5 (%) Average emergency medical admission rate (%) Mean LOS during in-patient hospitalization (day) Average medical in-patient bed occupancy (%) Monthly medical in-patient admission (N) Mean LOS in ED (h)
9922 20.4 79.6 57.2
9622 20.6 79.4 42.8
300 0.2 0.2 14.4
0.279 0.774 0.774 <0.001
5.16
4.13
1.03
<0.001
99.7
93.5
6.2
0.006
1247 4.42
1060 4.46
187 0.04
0.673 0.699
Note: LOS = length of stay; ED = emergency department; EMW = Emergency Medicine Ward; Triage Category 1 = critical; Triage Category 2 = emergency; Triage Category 3 = urgent; Triage Category 4 = semi-urgent; Triage Category 5 = non-urgent.
results were consistent with the primary goal of EMWs, that is, to reduce avoidable admissions and LOS with multidisciplinary care. EMWs provide a setting not only for ‘‘treating and reviewing’’ but also for executing care plans and expediting investigations. EMWs are tailor-made for certain disease-specific patient groups and aimed at reducing in-patient admission rates and LOS (Hospital Authority, 2010). Despite the transfer of nearly one-third of the EMW patients to a medical unit for further management, the overall LOS during in-patient hospitalization was reduced, relative to that prior to the EMW operation. This significant decrease in LOS during in-patient hospitalization emphasizes the effectiveness of EMWs in addressing access block, thereby improving patient flow in ED. Williams et al. (2000) found that the establishment of a formal ED observation ward decreased overall hospital bed days and LOS by 23% and 30%, respectively. Moreover, Richardson (2002) demonstrated the access-block effect; that is, a strong relationship was observed between in-patient LOS and the arrival of access block patients on an in-patient ward. Access-block patients (i.e., those who stay in the ED for more than 8 h) have a longer in-patient LOS than the no-block group. The EMW, an alternative choice for in-patient hospitalization, explicitly provides possible throughput solutions to access block. Clinically, medical bed occupancy rate was reduced to 93.5% with a mean difference of 6.2% with the EMW operation. Reducing the hospital occupancy rate to the target level (i.e., 85%) can effectively solve overcrowding (Australasian College for Emergency Medicine, 2004). The total number of medical in-patient admissions was reduced after the establishment of the EMW. Therefore, EMWs significantly alleviate the attendance pressure at medical units. Inadequate in-patient bed capacity mainly contributes to ED overcrowding (Derlet, 2002; Jayaprakash et al., 2009), resulting in increased LOS in the ED and consumption of aggregate resources. Asplin’s input–throughput–output conceptual model of ED overcrowding, clearly states the chain of consequences in an acute care system (Asplin et al., 2003). These three components are interdependent, that is, blockage of the output process can severely impede the throughput system. For instance, the lack of available in-patient beds contributes to in-patient boarding in ED, thus consuming emergency resources and delaying evaluation of new patients. The availability of in-patient beds and LOS in the ED potentially contribute to ED overcrowding. The present study found that the mean LOS in EDs before admission was only 4.46 h in a regional hospital, which is relatively acceptable compared to those in other countries. In the US, in-patient boarding commonly occurs in EDs, and critically ill patients need to wait for more than 5 h until an in-patient critical care bed becomes available (Andrulis et al., 1991). Despite the lack of a significant difference in the mean LOS in the ED before and after the establishment of the EMW, decreases in in-patient bed occupancy and LOS during
in-patient hospitalization directly improved hospital bed capacity. Harris and Sharma (2010) reported that a 1% increase in bed capacity is associated with a 2.99% decrease in mean patient care time. The unique nature and functions of EMW explicitly demonstrated the effectiveness in relieving ED overcrowding. The present study failed to compare cost reductions before and after the establishment of the EMW. In other countries, several studies have been conducted on EMW cost-effectiveness analysis. Goodacre and Dixon (2005) reported that a short-stay unit improved the outcome at costs lower than that of routine care. Limitations This study presents a general evaluation of the effectiveness of a typical EMW in a regional hospital and may not be applicable to all EMWs in Hong Kong. This limitation is attributed to the differences in staff profile and admission criteria of each unit or EMW, depending on its local needs. Further studies may compare the EMW with a similar medical unit in the same hospital and involve the specific groups of patients who benefited from the implementation of EMW. In evaluating the effectiveness of EMWs, patient satisfaction and staff perception can also be regarded as key performance indicators. These indicators could be considered in future studies. Costeffectiveness analysis may be used to determine future corporate directions and developments of EMWs. Future studies should focus on the cost-effectiveness analysis of EMWs in comparison to a similar subacute medical unit. Conclusions With advances in technology, efforts have been focused on the effective and efficient provision of care, as well as cost-effectiveness. Studies on the cost-effectiveness of an EMW or a short-stay unit have been rarely conducted during the past decade. The present study supports the benefits of the EMW service and elucidates this patient care approach to handling subacute medical cases. EMW service could significantly influence streamlined patient flow and reduce both the LOS during in-patient hospitalization and avoidable medical admission, thereby reducing costs. This study also provides a direction for extending the scope of service of EMWs to other areas of specialization, such as surgery and orthopedics. Acknowledgments The researchers thank all the staff of the Emergency Department of Alice Ho Miu Ling Nethersole Hospital for their participation in the study and The Nethersole School of Nursing in data management.
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References Andrulis, D.P., Kellermann, A., Hintz, E.A., Hackman, B.B., Weslowski, V.B., 1991. Emergency departments and crowding in United States teaching hospitals. Annals of Emergency Medicine 20 (9), 980–986. Asplin, B.R., Magid, D.J., Rhodes, K.V., Solberg, L.I., Lurie, N., Camargo, C.A., 2003. A conceptual model of emergency department crowding. Annals of Emergency Medicine 42 (2), 173–180. Australasian College for Emergency Medicine, 2002. Policy document-standard terminology. Emergency Medicine Australasia 14 (3), 337–340. Australasian College for Emergency Medicine, 2004. Access Block and Overcrowding in Emergency Departments. Australasian College for Emergency Medicine, Australia. Bullard, M.J., Villa-Roel, C., Guo, X., Holroyd, B.R., Innes, G., Schull, M.J., Vandermeer, B., Ospina, M., Rowe, B.H., 2012. The role of a rapid assessment zone/pod on reducing overcrowding in emergency departments: a systematic review. Emergency Medicine Journal 29 (5), 372–378. Cooke, M.W., Higgins, J., Kidd, P., 2003. Use of emergency observation and assessment wards: a systematic review. Emergency Medicine Journal 20, 138–142. Cooke, M.W., Wilson, S., Halsall, J., Roalfe, A., 2004. Total time in English accident and emergency departments is related to bed occupancy. Emergency Medicine Journal 21 (5), 575–576. Daly, S., Campbell, D.A., Camerpn, P.A., 2003. Short-stay units and observation medicine: a systematic review. Medical Journal of Australia 178 (11), 559–563. Derlet, R.W., 2002. Overcrowding in emergency departments: increased demand and decreased capacity. Annals of Emergency Medicine 39 (4), 430–432. Derlet, R.W., Richards, J.R., 2000. Overcrowding in the nation’s emergency departments: complex causes and disturbing effects. Annals of Emergency Medicine 35 (1), 63–68. Forero, R., Hillman, K.M., McCarthy, S., Fatovich, D.M., Joseph, A.P., Richardson, D.B., 2010. Access block and ED overcrowding. Emergency Medicine Australasia 22 (2), 119–135. Gonnah, R., Hegazi, M.O., Hmdy, I., Shenoda, M.M.M., 2008. Can a change in policy reduce emergency hospital admissions? Effect of admission avoidance team, guideline implementation and maximising the observation unit. Emergency Medicine Journal 25 (9), 575–578. Goodacre, S., Dixon, S., 2005. Is a chest pain observation unit likely to be cost effective at my hospital? Extrapolation of data from a randomised controlled trial. Emergency Medicine Journal 22 (6), 418–422. Harris, A., Sharma, A., 2010. Access block and overcrowding in emergency departments: an empirical analysis. Emergency Medicine Journal 27 (7), 508– 511.
Hoot, N.R., Aronsky, D., 2008. Systematic review of emergency department crowding: causes, effects, and solutions. Annals of Emergency Medicine 52 (2), 126–136. Hospital Authority, New Territories East Cluster, 2008. Emergency medicine ward operation manual. In: AHNH, A&E Department (Eds.). Hospital Authority, New Territories East Cluster, Hong Kong. Hospital Authority, 2010. Management of Accident and Emergency Services. Internal Audit Report. Hospital Authority, Hong Kong. Jayaprakash, N., O’Sullivan, R., Bey, T., Ahmed, S.S., Lotfipour, S., 2009. Crowding and delivery of healthcare in emergency departments: the European perspective. Western Journal of Emergency Medicine 10 (4), 233–239. Juan, A., Salazar, A., Alvarez, A., Perez, J.R., Garcia, L., Corbella, X., 2006. Effectiveness and safety of an emergency department short-stay unit as an alternative to standard inpatient hospitalisation. Emergency Medicine Journal 23 (11), 833– 837. Mace, S.E., Graff, L., Mikhail, M., Ross, M., 2003. A national survey of observation units in the United States. American Journal of Emergency Medicine 21 (7), 529–533. Martinez, E., Reilly, B.M., Evans, A.T., Roberts, R.R., 2001. The observation unit: a new interface between inpatient and outpatient care. American Journal of Emergency Medicine 110 (4), 274–277. Richardson, D., 2001. Association of access block with decreased ED performance [abstract]. Academic Emergency Medicine 8 (5), 575–576. Richardson, D.B., 2002. The access-block effect: relationship between delay to reaching an inpatient bed and inpatient length of stay. Medical Journal of Australia 177 (9), 492–495. Roberts, M.V., Baird, W., Kerr, P., O’Reilly, S., 2010. Can an emergency departmentbased clinical decision unit successfully utilize alternatives to emergency hospitalization? European Journal of Emergency Medicine 17 (2), 89–96. Schneider, S.M., Gallery, M.E., Schafermeyer, R., Zwemer, F.L., 2003. Emergency department crowding: a point in time. Annals of Emergency Medicine 42 (2), 167–172. Scott, I., Vaughan, L., Bell, D., 2009. Effectiveness of acute medical units in hospitals: a systematic review. International Journal of Quality in Health Care 21 (6), 397– 407. Sprivulis, P.C., Da Silva, J.A., Jacobs, I.G., Frazer, A.R., Jelinek, G.A., 2006. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Medical Journal of Australia 184 (5), 208–212. Williams, A.G., Jelinek, G.A., Rogers, J.A., Wenban, J.A., Jacobs, I.G., 2000. The effect on hospital admission profiles of establishing an emergency department observation ward. Medical Journal of Australia 173 (8), 411–441.
Contents lists available at ScienceDirect
International Emergency Nursing journal homepage: www.elsevier.com/locate/aaen
Effectiveness of Emergency Medicine Wards in reducing length of stay and overcrowding in emergency departments Shuk Man Lo RN BSN MPH FHKAN (Emergency) a,⇑, Kenny Tze Ying Choi RN BSN FHKAN (Emergency), Registered Nurse b, Eliza Mi Ling Wong RN BHS MHA PhD, Assistant Professor c, Larry Lap Yip Lee MRCSEd FHKAM (Emergency Medicine), Associate Consultant a, Richard Sai Dat Yeung FCEM FHKAM (Emergency Medicine), Consultant a, Jimmy Tak Shing Chan FCEM FHKAM (Emergency Medicine), Chief of Service a, Sek Ying Chair RN MBA PhD, Professor c a
Emergency Department, Alice Ho Miu Ling Nethersole Hospital, Tai Po, New Territories, Hong Kong Special Administrative Region Emergency Department, Tuen Mun Hospital, New Territories West, Hong Kong Special Administrative Region c The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region b
a r t i c l e
i n f o
Article history: Received 24 May 2013 Received in revised form 14 August 2013 Accepted 17 August 2013
Keywords: Emergency Medicine Ward Overcrowding Effectiveness Emergency Department Length of stay Service development
a b s t r a c t Objective: This study aims to evaluate the effectiveness of an Emergency Medicine Ward (EMW) in reducing the length of stay (LOS) in the emergency department, length of hospitalization, emergency medical admission rate, and the hospital bed occupancy rate. Methods: This study is a cross-sectional, observational study with a retrospective, quantitative record review conducted at the EMW of a regional acute hospital in Hong Kong from January 2009 to June 2009. Results: During the study, a retrospective audit was conducted on 1834 patient records. The five main groups of patients admitted into EMW suffered from cardiac disease (26.5%), pneumonia (19.6%), dizziness (16.2%), Chronic Obstructive Pulmonary Disease (12.3%), and gastroenteritis (7.9%). The mean LOS in the EMW was 1.27 days (SD = 0.59). The average emergency medical admission rate within the six-month period was significantly reduced relative to that before the EMW became operational (January 2008 to June 2008). Clinically, the medical in-patient bed occupancy was significantly reduced by 6.2%. The average LOS during in-patient hospitalization after the EMW was established decreased to 4.13 days from the previous length of 5.16 days. Conclusions: EMWs effectively reduce both the LOS during in-patient hospitalization and the avoidable medical admission rate. Ó 2013 Elsevier Ltd. All rights reserved.
Introduction The healthcare system is increasingly pressured to accommodate the increasing demand for healthcare services. Aging population, increasing hospitalization, and shortage in hospital beds are regarded as public, economic, and healthcare concerns. Long wait times for hospital bed availability and overcrowding in emergency departments (EDs) are commonly observed. These occurrences may delay patient’s treatment and compromise the quality of healthcare provided to patients (Derlet and Richards, 2000). ED overcrowding is defined as ‘‘the situation where ED function is impeded primarily because the number of patients waiting ⇑ Corresponding author. Address: Alice Ho Miu Ling Nethersole Hospital, Accident and Emergency Department, 11 Chuen On Road, Tai Po, New Territories, Hong Kong Special Administrative Region. Tel.: +852 26892145; fax: +852 26671205. E-mail address: [email protected] (S.M. Lo). 1755-599X/$ - see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ienj.2013.08.003
to be seen, undergoing assessment and treatment, or waiting for departure exceeds either the physical or staffing capacity of the ED’’ (Australasian College for Emergency Medicine, p. 340). ED overcrowding is identified as multi-factorial and complex (Hoot and Aronsky, 2008) and commonly associated with extended wait times, lack of ED staff (Schneider et al., 2003), increased patient acuity (Jayaprakash et al., 2009), hospital bed occupancy (Cooke et al., 2004), as well as insufficient physical environment and access block (Forero et al., 2010). Access block is referred to as ‘‘the situations where patients in the ED requiring inpatient care are unable to gain access to appropriate hospital beds within a reasonable time frame’’ (p. 340) (Australasian College for Emergency Medicine, 2002). Access block and consequent ED overcrowding exert influence on the quality of emergency care (Richardson, 2001), patient morbidity and mortality (Sprivulis et al., 2006), as well as staff and patient satisfaction (Derlet and Richards, 2000).
S.M. Lo et al. / International Emergency Nursing 22 (2014) 116–120
In response to these problems, strategies for coping with the increasing demand for hospital beds have been implemented. Chest pain observation units (Martinez et al., 2001), rapid assessment zones (Bullard et al., 2012), and clinical decision units (Roberts et al., 2010) have evolved to meet the demands of ED in the US, Canada, and the UK. They provide alternatives to the management of specific disease groups of patients in overcoming access block and consequent ED overcrowding. In Hong Kong, Emergency Medicine Wards (EMWs) (similar to short-stay unit) have emerged because of their potential to reduce access block and streamline appropriate health service delivery.
Background EMWs were developed in 2008. To date, 68% of EDs in Hong Kong offer EMW service. EMWs aim to reduce avoidable hospital medical admissions and consequent ED overcrowding, as well as reduce costs. Despite variations in EMWs, these EMWs share a similar mission and are commonly governed by the Hospital Authority (HA). The EMWs provide tailor-made services for the region population under study. First, the care was protocol-driven to a specific group of patients with reference to individual departmental policies. The protocols used [i.e. chest pain, hypertension (HT), and Chronic Obstructive Pulmonary Disease (COPD) protocols] were derived from international guidelines and evidence and then modified to suit the local setting and culture. We sought the approval of a panel of medical consultants, nurse managers, and nurse specialists in emergency medicine. The patient care service also encouraged inter-departmental and inter-disciplinary collaboration by an inpatient consultation and referral system, such as community nurse service and a geriatric team. Second, ward rounds were conducted by emergency specialists who perform four to six rounds per day. With this approach, all patients were treated promptly (Hospital Authority, 2008). In this acute hospital in the region, the EMW manages almost all medical patients, except those requiring airborne precautions, suffering from renal failure and on continuous ambulatory peritoneal dialysis, and critically ill. Patients are expected to be in a stable condition and discharged within 48 h. If the medical condition requires longer hospitalization and specialty care, the patient is transferred to an appropriate medical unit. The process ultimately aims to improve the quality of medical care through extended observation and multi-disciplinary care and simultaneously reduce inappropriate hospital admission and healthcare costs. EMWs provide alternative in-patient beds for subacute patients (Hospital Authority, 2008). Systematic reviews have been conducted on the effectiveness of all similar types of short-stay, observation, and subacute medical units. Numerous studies have shown that these units can effectively reduce mortality, length of stay (LOS), and access block, as well as improve staff and patient satisfaction (Cooke et al., 2003; Daly et al., 2003; Scott et al., 2009). However, studies have rarely been conducted in Asian countries. In Hong Kong, the future development of EMWs remains uncertain because of the emergence of different EMW models. The effectiveness of existing systems in each hospital must first be ascertained prior to the conclusive identification of the model that works effectively. Cost-effective resource allocation for EMW can be determined subsequently. The overall purpose of the present study is to assess the role, effectiveness, and future direction of EMWs in addressing the global problem of hospital bed availability (access block) and the increasing demand for quality service, considering that EMWs have been operational for four years. This study aims to evaluate the effectiveness of EMWs in terms of LOS in ED and hospitalization, medical in-patient admission rate, and bed occupancy.
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Methods Study design and setting This study is a cross-sectional, observational study involving a quantitative, retrospective review of the ED records of all EMW patients during the study period. This study was conducted with the approval of the joint Chinese University of Hong Kong–New Territories East Cluster clinical research ethical committee. The EMW is located in a regional government acute care hospital with 583 beds, which serves approximately 300,000 people in the local district. According to the internal statistics of ED, the average daily ED attendance in 2008 was nearly 327, and the medical admission rate constituted 55.31% of all emergency admissions. Moreover, the overall in-patient bed occupancy rate reached 98.8%. The 26-bed unit EMW was established in December 2008. Data collection The data collection periods were divided into two parts. The first part included the EMW data collected from January to June 2009; the ED records of all adult patients were retrieved during this period. Adult patients who were provided care for their medical illnesses at the ED and then admitted to the EMW for continuity of care were included. Meanwhile, part two included the data of a group of patients with similar diseases prior to the establishment of the EMW (i.e., from January to June 2008). All data were retrieved retrospectively through the Clinical Management System, a Hong Kong-wide computerized patient management system of the HA. Established in 1990, HA is a statutory body responsible for managing public hospitals in Hong Kong. Fig. 1 illustrates the conceptual framework for analyzing the effectiveness of EMW. Outcome measurement Outcome measurements included the ED first attendance, triage category, LOS of in-patient hospitalization, LOS in ED, medical inpatient admission number, and bed occupancy. These outcomes with and without EMW were compared. Data analysis Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 20.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were presented to summarize the demographic and clinical data. The data consisted of age, gender, provisional diagnosis, triage category, past health, final disposal from the EMW, and LOS in the EMW and the ED. T-tests were used to measure the differences in LOS during in-patient hospitalization, medical in-patient admission, and bed occupancy before and after the establishment of the EMW. The level of significance was set at 5% in all comparisons. Results From January to June 2009, the average ED first attendance was calculated as 319 patients per day, with a total of 1834 EMW admissions. Among the eligible EMW patients (N = 1834), 56% consisted of male patients. Most patients were elderly, with a mean age of 69.36 (SD = 18.29). Nearly 85% of the patients suffer from significant comorbidities, such as hypertension, diabetes mellitus, heart disease, and COPD. The five main disease categories were cardiac disease (26.5%; N = 486), pneumonia (19.6%; N = 359), dizziness (16.2%; N = 297), COPD (12.3%; N = 226), and gastroenteritis (7.9%; N = 145) (Table 1). Most of these patients were triaged in
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ED patients require hospitalization for continuity of care Screening by Emergency Specialists
EMW 20 medical beds + 6 post-operative beds Operated by emergency specialists and nurses
Patient disposition 1. 2. 3.
Admit medical unit Admit EMW if meet the criteria #
Discharge home/old aged home directly Transfer to convalescent hospital Transfer to medical unit for continuity of care
Effectiveness
Notes: # EMW Admission criteria All medical cases are admitted to EMW except: a) Patient requiring airborne precaution; b) Renal failure patient on CAPD; and c) Patient with critical clinical condition
Length of stay in Emergency Department Length of stay during in-patient hospitalization Emergency Medical admission rate Medical in-patient bed occupancy
Expected Outcome Alleviate Emergency Department overcrowding environment And reduce LOS during in-patient hospitalization
Fig. 1. Conceptual framework on the effectiveness of Emergency Medicine Ward (EMW).
Table 1 Reason for admission into EMW. Reasons of admission into EMW Cardiac problem (hypertension, coronary heart disease, arrhythmia) Pneumonia/fever Dizziness/neurological problem COPD Gastroenteritis Diabetes mellitus Decrease general condition Urinary tract infection Post convulsion Others (gout, buttock abscess, osteoarthritis, depression) Total
Frequency (N)
Percent (%)
486
26.5
359 297 226 144 88 86 33 4 110
19.6 16.2 12.3 7.9 4.8 4.7 1.8 0.2 6.0
1834
100.0
Note: EMW = Emergency Medicine Ward; COPD = Chronic Obstructive Pulmonary Disease.
Table 2 Patient disposition in EMW. Final disposal from EMW
Frequency (%)
Discharge home/old aged home Transfer to medical unit of AHNH Transfer to convalescent hospital Transfer to medical unit, then convalescent hospital
1095 (59.7%) 504 (27.5%) 198 (10.8%) 37 (2%)
Total
1834 (100%)
Note: EMW = Emergency Medicine Ward.
Category 3 (52.9%) and Category 4 (43.9%). Their mean LOS in ED before and after admission to the EMW was 4.46 (SD 3.086) and 1.27 days (SD 0.59), respectively. With regard to their final discharge destination, 59.7% of the patients were discharged directly from the EMW (Table 2). These patients comprised only 1.4% of the emergency re-attendance rate within 48 h. Outcome measure (effectiveness) Table 3 summarizes the comparison of outcomes for the six months before the EMW (January to June 2008). No significant difference in the emergency first attendance and triage categories was indicated between these two periods. The average emergency medical admission rate was significantly reduced (mean difference: 14.4%, 95% CI: 12.6–16.2). Moreover, the medical in-patient
bed occupancy was significantly reduced by 6.2% (p = 0.006). The average number of patients admitted in the medical unit per month was reduced by 187. A significant difference was also indicated in the LOS of in-patient hospitalization before and after the establishment of the EMW, with a mean LOS of 4.13 ± 6.01 days in contrast to 5.16 ± 4.97 days (95% CI: 0.85–1.21). No significant difference was found in the mean LOS in ED. Discussion This study evaluated the function of EMW in relieving ED overcrowding during the winter surge period. In the hospital under study, the EMW mainly manages medical conditions such as cardiac problems (Hypertension and coronary heart disease), pneumonia, Chronic Obstructive Pulmonary Disease and dizziness. Similar to those other countries, medical patients contribute to the high admission rate for in-patient hospitalization. A national survey of observation units in the US revealed that 96.9% of patients suffer from medical illnesses such as chest pain/cardiac disease (Mace et al., 2003). The present study revealed that older adults with highly complex medical problems comprise the main group of patients admitted into EMW. Half of the EMW patients were in Category 3 (those with urgent clinical conditions) with increased severity of illness. Prior to the EMW operation, these patients were admitted into medical units, thereby increasing medical bed occupancy. Total medical in-patient admission was reduced significantly by 187 admissions monthly and the average emergency medical admission rate decreased by 15% relative to those prior to the EMW operation. This finding suggests that EMW shares the workload of medical units and contributes significantly to the decrease in total medical admission and admission rate. In the UK, the clinical decision unit (which is similar to EMW) also functions successfully as an alternative to emergency hospitalization (Roberts et al., 2010). In addition, the mean LOS in the EMW was only 1.27 days, and 60% of these patients were discharged directly from the EMW. This result indicates that a specific group of medical patients can be treated and managed efficiently by emergency specialists and nurses, whether they are in the EMW or an ED observation unit (EDOU). Gonnah et al. (2008) observed that EDOUs can effectively reduce the medical admission rate, especially for patients with chest pain (52.7%) and bronchial asthma (49.2%). In addition, Juan et al. (2006) reported that patients with COPD and were admitted into an ED short-stay unit showed a significantly lower mean LOS and mortality than those admitted into an in-patient unit. These
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S.M. Lo et al. / International Emergency Nursing 22 (2014) 116–120 Table 3 Outcome measure before and after the operation of EMW. Outcome
Before operation of EMW (January 2008 to June 2008)
After operation of EMW (January 2009 to June 2009)
Mean difference
P value
Monthly ED first attendance (N) Triage category 1–3 (%) Triage category 4–5 (%) Average emergency medical admission rate (%) Mean LOS during in-patient hospitalization (day) Average medical in-patient bed occupancy (%) Monthly medical in-patient admission (N) Mean LOS in ED (h)
9922 20.4 79.6 57.2
9622 20.6 79.4 42.8
300 0.2 0.2 14.4
0.279 0.774 0.774 <0.001
5.16
4.13
1.03
<0.001
99.7
93.5
6.2
0.006
1247 4.42
1060 4.46
187 0.04
0.673 0.699
Note: LOS = length of stay; ED = emergency department; EMW = Emergency Medicine Ward; Triage Category 1 = critical; Triage Category 2 = emergency; Triage Category 3 = urgent; Triage Category 4 = semi-urgent; Triage Category 5 = non-urgent.
results were consistent with the primary goal of EMWs, that is, to reduce avoidable admissions and LOS with multidisciplinary care. EMWs provide a setting not only for ‘‘treating and reviewing’’ but also for executing care plans and expediting investigations. EMWs are tailor-made for certain disease-specific patient groups and aimed at reducing in-patient admission rates and LOS (Hospital Authority, 2010). Despite the transfer of nearly one-third of the EMW patients to a medical unit for further management, the overall LOS during in-patient hospitalization was reduced, relative to that prior to the EMW operation. This significant decrease in LOS during in-patient hospitalization emphasizes the effectiveness of EMWs in addressing access block, thereby improving patient flow in ED. Williams et al. (2000) found that the establishment of a formal ED observation ward decreased overall hospital bed days and LOS by 23% and 30%, respectively. Moreover, Richardson (2002) demonstrated the access-block effect; that is, a strong relationship was observed between in-patient LOS and the arrival of access block patients on an in-patient ward. Access-block patients (i.e., those who stay in the ED for more than 8 h) have a longer in-patient LOS than the no-block group. The EMW, an alternative choice for in-patient hospitalization, explicitly provides possible throughput solutions to access block. Clinically, medical bed occupancy rate was reduced to 93.5% with a mean difference of 6.2% with the EMW operation. Reducing the hospital occupancy rate to the target level (i.e., 85%) can effectively solve overcrowding (Australasian College for Emergency Medicine, 2004). The total number of medical in-patient admissions was reduced after the establishment of the EMW. Therefore, EMWs significantly alleviate the attendance pressure at medical units. Inadequate in-patient bed capacity mainly contributes to ED overcrowding (Derlet, 2002; Jayaprakash et al., 2009), resulting in increased LOS in the ED and consumption of aggregate resources. Asplin’s input–throughput–output conceptual model of ED overcrowding, clearly states the chain of consequences in an acute care system (Asplin et al., 2003). These three components are interdependent, that is, blockage of the output process can severely impede the throughput system. For instance, the lack of available in-patient beds contributes to in-patient boarding in ED, thus consuming emergency resources and delaying evaluation of new patients. The availability of in-patient beds and LOS in the ED potentially contribute to ED overcrowding. The present study found that the mean LOS in EDs before admission was only 4.46 h in a regional hospital, which is relatively acceptable compared to those in other countries. In the US, in-patient boarding commonly occurs in EDs, and critically ill patients need to wait for more than 5 h until an in-patient critical care bed becomes available (Andrulis et al., 1991). Despite the lack of a significant difference in the mean LOS in the ED before and after the establishment of the EMW, decreases in in-patient bed occupancy and LOS during
in-patient hospitalization directly improved hospital bed capacity. Harris and Sharma (2010) reported that a 1% increase in bed capacity is associated with a 2.99% decrease in mean patient care time. The unique nature and functions of EMW explicitly demonstrated the effectiveness in relieving ED overcrowding. The present study failed to compare cost reductions before and after the establishment of the EMW. In other countries, several studies have been conducted on EMW cost-effectiveness analysis. Goodacre and Dixon (2005) reported that a short-stay unit improved the outcome at costs lower than that of routine care. Limitations This study presents a general evaluation of the effectiveness of a typical EMW in a regional hospital and may not be applicable to all EMWs in Hong Kong. This limitation is attributed to the differences in staff profile and admission criteria of each unit or EMW, depending on its local needs. Further studies may compare the EMW with a similar medical unit in the same hospital and involve the specific groups of patients who benefited from the implementation of EMW. In evaluating the effectiveness of EMWs, patient satisfaction and staff perception can also be regarded as key performance indicators. These indicators could be considered in future studies. Costeffectiveness analysis may be used to determine future corporate directions and developments of EMWs. Future studies should focus on the cost-effectiveness analysis of EMWs in comparison to a similar subacute medical unit. Conclusions With advances in technology, efforts have been focused on the effective and efficient provision of care, as well as cost-effectiveness. Studies on the cost-effectiveness of an EMW or a short-stay unit have been rarely conducted during the past decade. The present study supports the benefits of the EMW service and elucidates this patient care approach to handling subacute medical cases. EMW service could significantly influence streamlined patient flow and reduce both the LOS during in-patient hospitalization and avoidable medical admission, thereby reducing costs. This study also provides a direction for extending the scope of service of EMWs to other areas of specialization, such as surgery and orthopedics. Acknowledgments The researchers thank all the staff of the Emergency Department of Alice Ho Miu Ling Nethersole Hospital for their participation in the study and The Nethersole School of Nursing in data management.
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