The Journal of Emergency Medicine, Vol. 46, No. 5, pp. 706–710, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2013.08.111
Administration of Emergency Medicine
THE EFFECT OF BOARDERS ON EMERGENCY DEPARTMENT PROCESS FLOW Eoin Fogarty, MB,* Jean Saunders, PHD,† and Fergal Cummins, MB‡ *Emergency Department, University of Limerick Hospital, Limerick, Ireland, †Statistical Consulting Unit/CSTAR @ UL, Faculty of Education & Health Sciences (SCU affiliated to Department of Maths & Statistics), University of Limerick, Limerick, Ireland, and ‡Department of Emergency Medicine, University of Limerick Hospital, Dooradoyle, Limerick, Ireland Reprint Address: Eoin Fogarty, MB, Emergency Department, University of Limerick Hospital, Limerick, Ireland
, Abstract—Background: Emergency department (ED) overcrowding with boarders and waiting times are a significant concern in many countries. Objective: We aim to show the relationship between boarders in the ED and the percentage time to disposition in under 6 h for our ED patients. Method: A review was carried out to show the percentage of patients presenting to the ED compliant with a 6-h standard per day compared to the number of attendances, the number of admissions to the hospital, and the number of boarders in the ED per day. Results: Over the 2-year study period, there was an average 0.37% fall in the ED’s rate of compliance per day, with a 6-h standard for each boarder in the ED. Conclusion: Boarding patients in the ED has a negative effect on compliance with our 6-h standard of time to disposition. Ó 2014 Elsevier Inc.
ED that there needs to be a reduction in the number of boarders in our ED to be more compliant with this. The aim of this study is to show the relationship between having boarders in the ED and the ability to maintain a 6-h standard of time to disposition. METHOD We performed a review of all attendances in our ED from January 2010 to December 2011. The study was performed in our ED, which sees approximately 60,000 adult and pediatric patients per year and has a total of 512 inpatient beds across all specialties. All patient attendances in our ED are tracked by an Electronic Patient Information system–IMS Maxims (Dublin, Ireland). This allows us to ascertain the number of patients presenting per day, the number of admissions to the hospital per day, and the percentage of patients compliant with a 6-h standard to disposition per day. A logbook is kept in the ED and updated every day at 8:00 AM documenting the number of boarders in the ED. This time is being taken as it is taken nationally to assess the ED boarder count in the country. These variables were compared between January 2010 and December 2011 to demonstrate their relationship. Complete data were available from January 1, 2010 to December 23, 2010 and February 1, 2011 to December 22, 2011. Variables were checked for normality, and
, Keywords—overcrowding; process flow
INTRODUCTION Emergency Department (ED) overcrowding with boarders is a common international concern (1,2). It is widely reported in our media that ED boarding is unacceptable and causes various significant unnecessary complications, up to death, as a known consequence (3). There have been recent calls in Ireland for implementation of a 6-h standard for ED patients from time of arrival to time to disposition (disposition is a decision made that the patient is to be admitted or discharged from the ED) (4). There is a general consensus in our
RECEIVED: 12 September 2012; FINAL SUBMISSION RECEIVED: 13 July 2013; ACCEPTED: 20 August 2013 706
The Effect of Boarders on Emergency Department Process Flow
707
Figure 1. Histogram of compliance with 6-h standard.
where they were clearly nonnormal, nonparametric Spearman’s rank correlation was calculated instead of Pearson’s correlation. A regression model was used to model the best predictor for a 6-h standard for our ED. Data were analyzed using SPSS version 20 (IBM, Armonk, NY). These results are illustrated graphically on a scattergram and include a linear trend line inserted with standard Microsoft Excel software (Microsoft Corporation, Redmond, WA). Ethical approval was obtained from the local Ethics board. RESULTS During the study period, there were 712 days or 114,836 patient attendances reviewed. Overall data for the 2 years show that there was an average of 9.2 boarders in the ED
at 8:00 AM, and an average of 66% of patients were compliant with a 6-h standard (Figure 1). The 6-h standard was significantly negatively correlated with all three possible predictor variables (Figures 2–4). Pearsons correlation coefficient was 0.153, p < 0.001 with number of attendances per day, 0.482 with number of admissions per day, p < 0.001, and Spearman’s rank correlation was 0.333, p < 0.001 with number of boarders per day. Number of admissions was most highly correlated, and this can be seen in the attached scatterplots (Figure 3). The number of admissions also highly correlated with the number of attendances, Pearson’s correlation coefficient was 0.496, p < 0.001, and also with the number of boarders/inpatients awaiting an inhospital bed–Spearman’s rho = 0.144, p < 0.001. This means that a regressions model including all three predictor
Figure 2. Compliance with 6-h standard vs. number of attendances.
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E. Fogarty et al.
Figure 3. Compliance with 6-h standard vs. number of admissions.
variables will probably be ill-conditioned. The bestfitting model was found to be a model with the number of admissions and the number of boarders in the ED only. The final model for a percentage compliance with a 6-h standard was 93.1 0.523 number of admissions per day 0.373 number of boarders per day. This final model produced an R2 value of 29.7%, which means that 29.7% of the variation in percentage compliance is being explained by the number of admissions per day and the number of boarders per day. DISCUSSION This study shows a clear relationship between boarders in the ED and a delay of over 6 h to disposition from our ED.
Figure 4. Compliance with 6-h standard vs. number of boarders.
We believe these are important data for the future planning of key performance indicators in our ED. This is in keeping with previous studies that show a delay to disposition with ED boarders (5). Study Limitations No other variable, such as the seasonality or severity of illness on these particular days, was considered in these data. The data are also dependent on the reliability of the staff in updating the electronic patient information system. It would be difficult to assess the effect of these variables based on our available data. An assumption is being made that by using almost 2 full years of data, these potential confounders will have minimal effect.
The Effect of Boarders on Emergency Department Process Flow
CONCLUSION ED boarding has a negative effect on compliance with our 6-h standard, as expected. There is an average reduction of compliance with our 6-h standard by 0.37% for every boarder at 8:00 AM on that day over this 2-year study period in our ED after accounting for any reduction due to number of admissions. REFERENCES 1. Higginson I. Emergency department crowding. Emerg Med J 2012; 29:437–43.
709 2. Fogarty E, Cummins F. The effect of admitted patients in the emergency department on rates of hospital admissions. Emerg Med J 2013;30:766–7. 3. Sprivulis PC, Da Silva JA, Jacobs IG, Frazer AR, Jelinek GA. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust 2006;184:208–12. 4. Health Information and Quality Authority. Report of the investigation into the quality, safety and governance of the care provided by the Adelaide and Meath Hospital, Dublin incorporating the National Children’s Hospital (AMNCH) for patients who require acute admission. Dublin: Health Information and Quality Authority; 2012. 5. Asaro PV, Lewis LM, Boxerman SB. The impact of input and output factors on emergency department throughput. Acad Emerg Med 2007;14:235–42.
710
E. Fogarty et al.
ARTICLE SUMMARY 1. Why is this topic important? This topic is of importance to determine the effect of boarders on emergency department (ED) process flow. 2. What does this study attempt to show? The study attempts to show a relationship, or not, between having boarders in the ED and a delay in time to disposition from the ED. 3. What are the key findings? The study shows a clear negative effect of boarders on patient time to disposition. There is a reduction of compliance with our 6-h standard by 0.37% for every additional boarder at 8:00 am on that day in our ED. 4. How is patient care impacted? We believe that this is important in understanding the effects of boarders on patient flow.
http://dx.doi.org/10.1016/j.jemermed.2013.08.111
Administration of Emergency Medicine
THE EFFECT OF BOARDERS ON EMERGENCY DEPARTMENT PROCESS FLOW Eoin Fogarty, MB,* Jean Saunders, PHD,† and Fergal Cummins, MB‡ *Emergency Department, University of Limerick Hospital, Limerick, Ireland, †Statistical Consulting Unit/CSTAR @ UL, Faculty of Education & Health Sciences (SCU affiliated to Department of Maths & Statistics), University of Limerick, Limerick, Ireland, and ‡Department of Emergency Medicine, University of Limerick Hospital, Dooradoyle, Limerick, Ireland Reprint Address: Eoin Fogarty, MB, Emergency Department, University of Limerick Hospital, Limerick, Ireland
, Abstract—Background: Emergency department (ED) overcrowding with boarders and waiting times are a significant concern in many countries. Objective: We aim to show the relationship between boarders in the ED and the percentage time to disposition in under 6 h for our ED patients. Method: A review was carried out to show the percentage of patients presenting to the ED compliant with a 6-h standard per day compared to the number of attendances, the number of admissions to the hospital, and the number of boarders in the ED per day. Results: Over the 2-year study period, there was an average 0.37% fall in the ED’s rate of compliance per day, with a 6-h standard for each boarder in the ED. Conclusion: Boarding patients in the ED has a negative effect on compliance with our 6-h standard of time to disposition. Ó 2014 Elsevier Inc.
ED that there needs to be a reduction in the number of boarders in our ED to be more compliant with this. The aim of this study is to show the relationship between having boarders in the ED and the ability to maintain a 6-h standard of time to disposition. METHOD We performed a review of all attendances in our ED from January 2010 to December 2011. The study was performed in our ED, which sees approximately 60,000 adult and pediatric patients per year and has a total of 512 inpatient beds across all specialties. All patient attendances in our ED are tracked by an Electronic Patient Information system–IMS Maxims (Dublin, Ireland). This allows us to ascertain the number of patients presenting per day, the number of admissions to the hospital per day, and the percentage of patients compliant with a 6-h standard to disposition per day. A logbook is kept in the ED and updated every day at 8:00 AM documenting the number of boarders in the ED. This time is being taken as it is taken nationally to assess the ED boarder count in the country. These variables were compared between January 2010 and December 2011 to demonstrate their relationship. Complete data were available from January 1, 2010 to December 23, 2010 and February 1, 2011 to December 22, 2011. Variables were checked for normality, and
, Keywords—overcrowding; process flow
INTRODUCTION Emergency Department (ED) overcrowding with boarders is a common international concern (1,2). It is widely reported in our media that ED boarding is unacceptable and causes various significant unnecessary complications, up to death, as a known consequence (3). There have been recent calls in Ireland for implementation of a 6-h standard for ED patients from time of arrival to time to disposition (disposition is a decision made that the patient is to be admitted or discharged from the ED) (4). There is a general consensus in our
RECEIVED: 12 September 2012; FINAL SUBMISSION RECEIVED: 13 July 2013; ACCEPTED: 20 August 2013 706
The Effect of Boarders on Emergency Department Process Flow
707
Figure 1. Histogram of compliance with 6-h standard.
where they were clearly nonnormal, nonparametric Spearman’s rank correlation was calculated instead of Pearson’s correlation. A regression model was used to model the best predictor for a 6-h standard for our ED. Data were analyzed using SPSS version 20 (IBM, Armonk, NY). These results are illustrated graphically on a scattergram and include a linear trend line inserted with standard Microsoft Excel software (Microsoft Corporation, Redmond, WA). Ethical approval was obtained from the local Ethics board. RESULTS During the study period, there were 712 days or 114,836 patient attendances reviewed. Overall data for the 2 years show that there was an average of 9.2 boarders in the ED
at 8:00 AM, and an average of 66% of patients were compliant with a 6-h standard (Figure 1). The 6-h standard was significantly negatively correlated with all three possible predictor variables (Figures 2–4). Pearsons correlation coefficient was 0.153, p < 0.001 with number of attendances per day, 0.482 with number of admissions per day, p < 0.001, and Spearman’s rank correlation was 0.333, p < 0.001 with number of boarders per day. Number of admissions was most highly correlated, and this can be seen in the attached scatterplots (Figure 3). The number of admissions also highly correlated with the number of attendances, Pearson’s correlation coefficient was 0.496, p < 0.001, and also with the number of boarders/inpatients awaiting an inhospital bed–Spearman’s rho = 0.144, p < 0.001. This means that a regressions model including all three predictor
Figure 2. Compliance with 6-h standard vs. number of attendances.
708
E. Fogarty et al.
Figure 3. Compliance with 6-h standard vs. number of admissions.
variables will probably be ill-conditioned. The bestfitting model was found to be a model with the number of admissions and the number of boarders in the ED only. The final model for a percentage compliance with a 6-h standard was 93.1 0.523 number of admissions per day 0.373 number of boarders per day. This final model produced an R2 value of 29.7%, which means that 29.7% of the variation in percentage compliance is being explained by the number of admissions per day and the number of boarders per day. DISCUSSION This study shows a clear relationship between boarders in the ED and a delay of over 6 h to disposition from our ED.
Figure 4. Compliance with 6-h standard vs. number of boarders.
We believe these are important data for the future planning of key performance indicators in our ED. This is in keeping with previous studies that show a delay to disposition with ED boarders (5). Study Limitations No other variable, such as the seasonality or severity of illness on these particular days, was considered in these data. The data are also dependent on the reliability of the staff in updating the electronic patient information system. It would be difficult to assess the effect of these variables based on our available data. An assumption is being made that by using almost 2 full years of data, these potential confounders will have minimal effect.
The Effect of Boarders on Emergency Department Process Flow
CONCLUSION ED boarding has a negative effect on compliance with our 6-h standard, as expected. There is an average reduction of compliance with our 6-h standard by 0.37% for every boarder at 8:00 AM on that day over this 2-year study period in our ED after accounting for any reduction due to number of admissions. REFERENCES 1. Higginson I. Emergency department crowding. Emerg Med J 2012; 29:437–43.
709 2. Fogarty E, Cummins F. The effect of admitted patients in the emergency department on rates of hospital admissions. Emerg Med J 2013;30:766–7. 3. Sprivulis PC, Da Silva JA, Jacobs IG, Frazer AR, Jelinek GA. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust 2006;184:208–12. 4. Health Information and Quality Authority. Report of the investigation into the quality, safety and governance of the care provided by the Adelaide and Meath Hospital, Dublin incorporating the National Children’s Hospital (AMNCH) for patients who require acute admission. Dublin: Health Information and Quality Authority; 2012. 5. Asaro PV, Lewis LM, Boxerman SB. The impact of input and output factors on emergency department throughput. Acad Emerg Med 2007;14:235–42.
710
E. Fogarty et al.
ARTICLE SUMMARY 1. Why is this topic important? This topic is of importance to determine the effect of boarders on emergency department (ED) process flow. 2. What does this study attempt to show? The study attempts to show a relationship, or not, between having boarders in the ED and a delay in time to disposition from the ED. 3. What are the key findings? The study shows a clear negative effect of boarders on patient time to disposition. There is a reduction of compliance with our 6-h standard by 0.37% for every additional boarder at 8:00 am on that day in our ED. 4. How is patient care impacted? We believe that this is important in understanding the effects of boarders on patient flow.
