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It’s Getting…Crowded In Here

April 4, 2023

Written by Gabby Leonard

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Crowding in the Emergency Department (ED) can be attributed to systems failures across three different phases of ED care: input, throughput, and output of patients. This paper evaluates the reasons behind crowding and proposes solutions to mitigate this burdensome issue.

Why does this matter?
ED crowding has become a hot topic at a national level due to its direct correlation with higher morbidity/mortality, delayed pain control, delayed time to antibiotic administration, increased medical error and decreased patient satisfaction. Regarding the pediatric population, crowding increases our risk of missing critically ill children and often delays necessary therapeutic intervention.

It’s getting…crowded in here
Mandatory reporting of crowding metrics include patient’s length of stay, arrival-to-provider time, left-without-being-seen rate, median length of stay and decision-to-departure time. The three categories below breakdown our systems issues and provide potential solutions.

Input (patients coming to Pediatric ED)

  • Issues: Patient preference of treatment facility, social determinants of health, access to specialists, geographic proximity, mental-behavioral health emergencies and lack of available primary care
  • Solutions: Parallel process to register & triage, posted wait times, increased access to primary care (after-hours or care at home, telehealth/telepsych options), increased access to specialty care appointments outpatient

Throughput (patients in the Pediatric ED)

  • Issues: Space restriction, seasonal surges in disease, complex care requiring extensive evaluation, variable provider skills regarding pediatric management, language/cultural barriers, lack of subspecialty consults, requirement for psychiatric evaluation/admission
  • Solutions: Fast-track model for rapid assessment zone or provider in triage to expedite initial evaluation and workup, adequate staffing, patient flow coordinator nurse, scribes during seasonal surges and early identification for need for admission/bed assignment

Output (patients leaving Pediatric ED/hospital)

  • Issues: Boarding with lack of staffed inpatient beds, lack of access to appropriate outpatient care and follow-up
  • Solutions: Hospital policies to streamline admissions/distribute elective admissions, daily communication from leadership, early inpatient discharges or access to observational units

Crowding continues to pose a nationwide threat to patients and hospital systems. Identification of variables contributing to this as well as proposals for optimizing patient care remain at the forefront of Emergency Medicine.

Crowding in the Emergency Department: Challenges and Best Practices for the Care of Children. Pediatrics. 2023 Feb 20;e2022060972. doi: 10.1542/peds.2022-060972. Online ahead of print.

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