OVERCROWDING IN THE EMERGENCY DEPARTMENT (ED):

1. OVERCROWDING IN THE EMERGENCY DEPARTMENT (ED): PERCEPTION BY HEALTH WORKERS IN THE ACCIDENT AND EMERGENCY CENTRE, KOMFO ANOKYE TEACHING HOSPITAL (KATH) BY DR. NANA SERWAA A. QUAO

3. CO-AUTHORS • DR. GEORGE ODURO • DR. JOE BONNEY • DR. PAA KOBINA FORSON

4. OUTLINE • INTRODUCTION • PURPOSE • OBJECTIVE • METHOD • SAMPLE • RESULTS • DISCUSSION • RECOMMENDATION • CONCLUSION • REFERENCES

5. INTRODUCTION • Emergency department (ED) overcrowding is gradually becoming a growing trend in many hospitals worldwide. • According to a 2002 national US survey, more than 90% of large hospitals report EDs operating “at” or “over” capacity. • In a 2001 report, 91% of US ED directors (525 out of 575 directors) reported problematic crowding in their departments, and 39% reported overcrowding on a daily basis.

6. INTRODUCTION • Overcrowding can be defined as “a situation in which demand for service exceeds the ability to provide care within a reasonable time, causing physicians and nurses to be unable to provide quality care”. (CAEP & NENA, 2001) • Aboarded patient is defined as a patient who remains in the emergency department after the decision to admit him or her to the hospital has been made. (ACEP Joint taskforce, 2007)

8. INTRODUCTION • As part of the problem-solving process, it is important to distinguish what crowding means in the emergency department versus the inpatient units of most hospitals. • Inpatient units, when their normal patient beds are full, are considered “full” and thus not “capable” of taking more patients. • Emergency departments are considered “full” when all their rooms are full, all their hallway stretchers are full, and all their chairs are full. • Thus, there is a striking contrast between the emergency department and the inpatient units in their respective views of what constitutes “at capacity” or being crowded. (ACEP Joint Taskforce, 2007)

12. A number of effects have resulted from ED overcrowding: • Inadequate patient care • Prolonged delays in the treatment of pain and suffering • Long waiting times and patient dissatisfaction • Ambulance diversions • Decreased nurse/physician satisfaction • Negative effect on teaching and research • (Canadian Association of Emergency Physicians and National Emergency Nurses Affiliation, CJEM (2001)).

13. KATH ED receives an average of 84 patients per day and 28,000 patients in a year. • Overcrowding and long boarding hours has been a challenge in the ED

15. PURPOSE OF THE STUDY • To assess the perception and causes of patient overcrowding among health personnel and to identify strategies to reduce overcrowding in the emergency department.

16. SPECIFIC OBJECTIVES • To determine the perception of overcrowding in the emergency department among health personnel • To identify the factors contributing to overcrowding in the emergency department • To ascertain the effects of overcrowding on patient care among health personnel • To identify strategies to reduce patient overcrowding in the emergency department

17. ETHICAL CLEARANCE • The research was submitted to the Committee on Human Research, Publications and Ethics (CHRPE) at KATH, for ethical clearance before embarking on the study (REF: CHRPE/AP/359/15). • Permission was sought from the administrative heads of A&E Centre at KATH. • Verbal consent was sort from the health workers before participation.

18. METHOD • A cross-sectional study was used. • The study was carried out for three months in 2015. • Analysis was done using Epi Info 7 by CDC.

19. SAMPLE • A total of 513 health workers (236 health workers in emergency department, (47 doctors and189 nurses), 277 health workersin internal medicine, surgery, trauma and orthopaedics, EENT combined) work in the Emergency units of yellow, red, orange and CDU under the Emergency Department. • Systematic sampling was adopted for this study to reduce the potential of human bias in the selection of the population to be included in the sample.

20. SAMPLE • With a 5% margin of error and a 95% confidence interval, a sample size of 110 was obtained out of the total staff population in the Accident and Emergency Centre. • One-third of the total number was chosen and in each department, health workers were randomly selected for the study. • Using systematic random sampling method, 110 health workers were selected.

21. Questionnaire based interviews were conducted among health workers to give their perception about patient overcrowding and its effects. • Closed ended questions were administered. • The instruments for data collection were subjected to pre-testing to ascertain the validity and consistency prior to the study. No errors or ambiguities were identified after the pre-testing thus confirming the suitability of the tools.

22. RESEARCH QUESTION • What is the perception of overcrowding of patients in the emergency department among health personnel? • What are the effects of overcrowding in the emergency department on health care personnel? • What are the contributory factors to patient overcrowding in the emergency department? • Which strategies can be used to reduce patient overcrowding in the emergency department?

23. RESULTS • A total of 110 health workers were surveyed with 59 (53.64%) being nurses and 51(46.36%) as doctors. • Females were 52(47.27%) and males were 58 (52.73%). • All workers had attained some level of education with Diploma as the most attained41(42.27%). • Majority of the respondents were residents, 21(19.44%), senior nursing officers, 20(18.52%), and house officers, 14(12.96%).

24. UNIVARIATE ANALYSIS OF HEALTH WORKERS Source: Field Data, 2015

25. RANKS OF HEALTH WORKERS Source: Field Data, 2015

26. RESULTS • The average waiting time of a patient at the ED as perceived by majority ofhealth workers was 30minutes before being seen by a physician. • Health personnel thought that there was not much variation in the days when the ED is overcrowded but agreed afternoon shifts were mostly crowded among all shifts.

27. Source: Field Data, 2015

28. RESULTS • Health personnel most agreed strongly that inappropriate referrals 59.63% and delays in getting radiological imaging 49.07% were the main causes of overcrowding.

29. Source: Field Data, 2015

30. NEGATIVE EFFECTS OF OVERCROWDING ON PATIENT CARE Source: Field Data, 2015

32. Majority of the health workers (95%), said that overcrowding in the ED contributed to poor patient outcome. • Ways in which health workers think overcrowding contribute to poor patient outcome include: • staff exhaustion (40.37%), • compromised quality of patient care (36.70%), • standard procedures not followed(36.70%), • long waiting time of patients before being assessed by a physician(29.36%) and • poor working conditions(27.52%).

33. EFFECTS OF OVERCROWDING ON POOR PATIENT OUTCOME Source: Field Data, 2015

34. RESULTS • Health personnel strongly agreed that • Equipping district hospitals to handle non-emergency cases (77.78%), • Appropriate referral system (75.93%), • Provision of adequate logistics and consumables (57.41%) can help curb the problem of overcrowding.

35. Source: Field Data, 2015

36. RESULTS • A greater number of the respondents (98%) agreed that information about bed state on the wards should be sent to the ED as a means of curbingovercrowding whiles 2% thought it was not a good idea. • Those who agreed, majority responded that ward bed states should be sent every six hours (four times) in a day.

37. Best ways identified to send ward bed state information to the ward Source: Field Data, 2015

38. RECOMMENDATIONS • Internal Emergency Department Actions and Processes That Will Improve Access and Flow: • Limit triage to what is crucial and bypass triage altogether when beds are available. • Develop a fast track for treating simple fractures, lacerations, sore throats, etc. • Expand the practice of observation medicine. • Implement triage protocols.

39. Expand the size of the ED • Carefully evaluate staffing needs • Establish clearly defined turnaround-time(TAT) goals in the emergency department. • Decrease TAT associated with ancillary services • Provide additional staff during times of increased volume.

40. Hospital Actions and Processes That WillImprove Access and Flow • Match resources to needs • Create institutional awareness of the dangers associated with emergency department crowding due to boarding of emergency patients. • Address delays in moving emergency patients admitted to the hospital caused by waiting for nursing reports. • Examine the discharge process and measure all reasons for delays in discharge of the patient. • Establish hospital-wide protocols for addressing capacity issues in the emergency department and implement an alert system when the hospital is over capacity. • ACEP 2007

41. CONCLUSION • Overcrowding in the ED is perceived to cause staff burn-out and result in poor patient outcomes. Evidence-based interventions may improve overcrowding.

43. REFERENCES • Cowan, R.M. & Trzeciak, S., 2005. Clinical review: Emergency department overcrowding and the potential impact on the critically ill. Critical care (London, England), 9(3), pp.291–5. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15987383 [Accessed August 10, 2016]. • Canadian Association of Emergency Physicians and National Emergency Nurses Affiliation, 2001. Joint Position Statement on emergency department overcrowding. CJEM [Internet]. 2001 Apr 21 [cited 2016 Aug 12];3(2):82–4. Available from: http://www.journals.cambridge.org/abstract_S1481803500005285 • Forson PK (2011). An audit of emergency care at the Accident and Emergency Unit of KATH, Kumasi, Ghana. Masters Thesis Community Health Department, KNUST, Kumasi. (Unpublished)

44. REFERENCES • Mchugh, M. & Dyke, K.V., 2011. and Reducing Emergency Department Crowding : A Guide for Hospitals Improving Patient Flow Department Crowding : improving Patient Flow and Reducing Emergency Department Crowding, p.8. • Boarding Task Force Members et al., 2008. ACEP Task Force Report on Boarding Emergency Department Crowding: High-Impact Solutions, Available at: https://www.acep.org/content.aspx?id=32050 [Accessed September 6, 2016]. • Ntow Marie, 2014. College of health sciences in partial fulfillment of the requirements for the award of MPH degree in health services planning and management. Unpublished