Nese COLAK ORAY,1,* Sedat YANTURALI,1 Ridvan ATILLA,1 Gurkan ERSOY,1 and Hakan

TOPACOGLU2

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SUMMARY

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Introduction

Overcrowding occurs when no inpatient beds are available in hospital as a result of

too many patients with non-urgent medical conditions seeking emergency care.

[1]Emergency department (ED) overcrowding is an increasing problem worldwide.

Overcrowding is correlated with several negative outcomes, such as increased in-

hospital death rates, prolonged treatment times, a rise in preventable medical

errors, patients leaving without receiving medical advice from a physician or without

being examined in the ED, and repeated applications to hospital.2, 3

Among the reasons for ED overcrowding are an insufficient number of hospital beds,

a rise in ED applications, excessive critical patient numbers, an insufficient numbers

of nurse, delayed consultations, delayed radiological examinations, and a shortage

of ED physical space.[4]

There are no globally accepted standard criteria for measuring ED overcrowding.

However, five main scoring systems have been employed in studies regarding ED

overcrowding.5, 6, 7, 8, 9

1.
 Emergency Department Crowding Score, EDCS

2.

Real Time Emergency Analysis of Demand Indicators Score, READI

3.

Emergency Department Work Index, EDWIN

4.

National Emergency Department Overcrowding Study, NEDOCS

5.

Work Score

Hoot et al. compared overcrowding scoring systems and reported that EDWIN,

NEDOCS and Work Score provided powerful prediction of emergency service

overcrowding, with negative predictive values of approximately 94%.[10]

A new strategy has been introduced with an aim to reduce the overcrowding in the

our ED and accelerate turnover called the Electronic Blockage System (EBS). The

main principle of the EBS is to prioritize, patients awaiting admission to the ED. For
example, patients that are waiting clinical admission within the ED are registered

and all other admissions outside the ED are blocked in the electronic system.

In order to evaluate the success of the EBS based on the principle of priority being

given to patients in the ED in admission and reduce ED overcrowding, our study

evaluated ED overcrowding in the pre-EBS and early and late post-EBS periods.

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Materials and Methods

Study environment

The Dokuz Eyll University Hospital (DEUH) is one of two universities and four

ministry of health training and research hospitals providing tertiary casualty

department service in the Izmir with a metropolitan population of approximately 4

million. With its 925-bed capacity, it is the third-largest hospital in the province of

Izmir. The DEUH ED served 85,813 patients in 2011. Despite a rise in numbers of

patients applying to our hospital ED in recent years, the admission rates from the

ED to hospital have declined in relative terms since there has been no change in

department/intensive care admission rates (Table 1). The mean age of patients

applying was determined to be 46. Eight percent of the patients were able to be

admitted, while 4% transferred to another institution or left the ED of their own

volition. The majority (87%) were able to be seen at the ED and discharged. The ED

harbors 42 beds, consisting of: 1 resuscitation room, 11 monitored observation, 10

observation units, 5 for the trauma, 5 in other areas (ear-nose-and-throat, eye,

gynecology, psychiatry) and 10 additional beds. Sixteen beds are monitored and 6

have mechanical ventilators. There are two work shifts in the ED from 08:00 to18:00

and 18:00 to 08:00. Each shift includes one emergency physician, 5 or 6 emergency

residents (ER), 5 nurses, 5 medical students in their final year of school, 4 patient

care assistants, and 2 paramedics.

Table 1

Five-year emergency department admission numbers

Intervention technique: Electronic Blockage System

Before implementation, a meeting of the Emergency Medicine Coordination Board

was held at the DEUH Chief Medical Office with representatives of all the clinical

units in the hospital and members of the ED teaching staff. The following decisions

were made:

Empty beds in the hospital should always and without exception be

used for patients awaiting admission at the ED.

 In the presence of patients awaiting admission at the ED, other

admissions to relevant wards (polyclinics, for example) should be stopped

by the Hospital Information System (HIS), although admissions are to be

permitted once patients waiting at the ED have been admitted.

At transfers between institutions: if a request for a transfer to a clinical

department has come from an external institution, the patient is only to be

admitted if there are no patients awaiting admission in the ED.

An additional program to the HIS was written for the implementation of this system.

In the program, if there are patients in the ED awaiting admission to the relevant

ward, then other non-urgent polyclinic admissions are blocked, and admissions are

only permitted once patients in the ED have been admitted.

Study protocol

Once approval had been granted by the Dokuz Eyll University Faculty of Medicine

Clinical Research Ethical Committee, the study was performed at the DEUH Adult ED

where patients aged 18 and over are accepted. Three different oneweek periods

were selected for data collection: the pre-EBS period (one week immediately before

EBS), the early post-EBS period (one week after EBS) and the late post-EBS period,

the first week in the second month after EBS). A questionnaire was given out that

consisted of questions evaluating ED overcrowding every day throughout the course

of the study (NEDOCS scoring) and questions regarding ED personnel (senior ER and
senior nurse and paramedic) perceptions related to overcrowding. The

questionnaire was completed every day at 07:00 (time of fewest applications to the

ED), 17:00 (time of average ED density) and 22:00 (time of most applications to the

ED) and the mean of the values obtained taken. In order to evaluate perceptions of

overcrowding, the following scoring system was used; 1- calm, 2- normal, 3-

crowded or 4- Severely crowded. Additionally, a senior ER personnel was asked

about the ED turnaround and the replies scored 1- fast, 2- normal, 3- slowed or 4-

stopped.

Crowding measurement technique

NEDOCS scoring was used for overcrowding measurement.[1]

1.

Patient index: Number of existing patients in the ED to ED bed numbers.

2.

Admission index: Number of patients in the ED waiting for hospital beds to

become available to number of hospital beds.

3.

Number of ED patients using mechanical ventilators.

 4.

Admission time: Longest waiting time among patients awaiting admission to

the ED.

5.

Registration time: Time spent in the waiting room by the last patient taken for

admission to an ED bed.

NEDOCS values were calculated on the basis of our hospital standard emergency

bed number of 42 and a total hospital bed number of 925 on

the[Link] web site. At analysis of scores between 0 and 200 at

NEDOCS scoring, 100 points was taken as the cut-off value. Accordingly,

050 points; calm,

51100 points; busy,

101140 points: crowded,

141180 points: seriously crowded,

181 and above: dangerously crowded.

Statistical analysis
The data collected were recorded onto Statistical Package for Social Sciences (SPSS)

15.0. One-way ANOVA and the Kruskal Wallis test were used to compare means, and

significance was set at p0.05.

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Results

A number of patients, including those in the ED, awaiting admission to hospital,

using mechanical ventilators, waiting the longest time, admitted to the ED in the

previous one hour, and mean NEDOCS values at time of measurement in all three

periods are given in Table 2.

Table 2

Pre-EBS, early post-EBS and late post-EBS results

No significant difference was determined between the groups in terms of existing

numbers of patients in the ED and number of patients admitted to the ED in the last

hour (p=0.074 and p=0.969). Examination of numbers of patients awaiting

admission at the ED revealed a significantly lower number of patients awaiting

admission in the early post-EBS period compared to the pre-EBS and late post-EBS
periods (p=0.0001 and p=0.00, respectively). There was no significant difference

between the pre-EBS and late post-EBS periods (p=0.713).

Comparison of mean waiting for admission times of those patients waiting for

longest at the ED revealed a statistically significant difference between all three

periods (p=0.0001, p=0.0001 and p=0.007, respectively). The period with the

shortest waiting time was the early post-EBS period.

Comparison of numbers of patients using mechanical ventilators in the ED revealed

no significant difference between the pre-EBS and early post-EBS periods, while the

number of patients using mechanical ventilators in the late post-EBS period was

significantly higher than in the other periods (p=0.449, p=0.0001 and p=0.0001,

respectively).

Comparison of mean NEDOCS values by periods revealed a significantly lower

NEDOCS value in the early post-EBS period compared to the other periods (Kruskal

Wallis test, p0.0001, Figure 1).

Figure 1

NEDOCS Values by Periods.

Comparing mean NEDOCS values by perceptions of crowding of each personnel

group in the ED, perceptions of crowding increase as NEDOCS values rise. However,

no correlation was determined between NEDOCS values and perceptions of

crowding of nurses and paramedics (Table 3).

Table 3

Mean NEDOCS values by Emergency Department Staff Crowing Perceptions

Comparing ED personnel perceptions of crowding in the pre- and post-EBS periods,

no significant internal difference was determined in the doctor, nurse or paramedic

groups (Table 4).

Table 4

Emergency Department Personnel Perceptions of Crowding and Work Turnaround

Comparing NEDOCS values with work turnaround evaluations of senior ED

physicians, as NEDOCS values rose they considered there was a deceleration in

turnaround (p=0.0001, Table 5).

Table 5

Mean NEDOCS Values by Senior Emergency Department Physician Work Turnaround

Evaluation

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Discussion

Overcrowding is a common problem in many EDs. There have been several previous

studies on the subject. However, there are still no effective and standard

recommendations aimed at resolving the problem of overcrowding.[11] Hospitals

produce their own solutions supplementary to nationwide health policies in order to

prevent overcrowding.[12] EBS was implemented in our hospital for the purpose of

reducing the overcrowding problem.

Although there was no significant variation in numbers of patients applying to the

emergency service and existing patient numbers measured at that time in the

department in the early period when EBS was implemented, NEDOCS values
declined from dangerously overcrowded to overcrowded (196 and 131,

respectively). We ascribe this to patients being admitted to the relevant

departments more quickly and the number of patients awaiting admission in the ED

decreasing to a lower number of patients using mechanical ventilators in the ED at

that time and to a shortening in waiting times among patients awaiting admission in

the ED.

Due to the lack of sufficient intensive care beds, the EBS system planned for all

admissions from the ED could only be applied to ED admissions. This in turn led to

elevated NEDOCS values at times when there were large numbers of patients

awaiting intensive care admission. There was no significant variation in numbers of

patients applying to the ED and momentarily measured existing patient numbers in

the department in the late post-EBS period compared to the pre-EBS and early post-

EBS period. This was quite possible due to an increase in the numbers of patients

using mechanical ventilators and awaiting intensive care admission. In addition,

there was also a rise in existing patient numbers in the ED and patients awaiting

admission. This in turn led to NEDOCS values again reaching overcrowded levels in

the late post-EBS period. A rise in the number of patients using mechanical

ventilators in the ED and in the number of patients awaiting admission to intensive

care, even if not using mechanical ventilators, will mean EDs turning into chronic

care centers. A solution needs to be found to this, since it will mean a decline in the
quality of care given to other patients applying to the ED and requiring first aid. We

think that this basic aim of the EBS system can be achieved by increasing the

number of intensive care beds and initiating the measure for intensive care.

Crowding perceptions of doctors working in the ED rose in line with NEDOCS values.

However, no such relationship was determined for nurses and paramedics.

Examination of the effect of the EBS system on ED personnel perceptions of

crowding revealed no significant differences within the doctor, nurse and paramedic

groups in the pre- and post-EBS periods. Duration of care in the ED is reported to be

associated with numbers of ED doctors and nurses and hospital capacity.[13] The

reason for the difference in crowding perceptions between doctors and nurses may

be that the number of patients per doctor in our ED is sufficient and meets

standards, while nurse numbers are inadequate. In addition, despite a partial

improvement in NEDOCS values in the post-EBS period, persisting measurement at

the crowded level may also affect perceptions of crowding.

Senior ER in our study thought that as NEDOCS values rose there was a slow-down

in work turnaround. As crowding in the ED rises, personnel perceptions of crowding

worsen and work turnaround decelerates in parallel with this. Increased ED

crowding and a slowdown in work turnaround may have led to fatigue, or personnel

fatigue may affect perceptions of crowding as a vicious circle, in a vicious circle.

However, fatigue levels were not measured in our study.

Limitations

The effectiveness of EBS was measured using only NEDOCS scoring. Other

parameters that can measure effectiveness, such as mean durations of

hospitalization and hospitalization levels, were not investigated. In addition, EBS

was not applied to intensive care admissions. We therefore think that the number of

patients awaiting intensive care admission in the post-EBS period may have resulted

in the NEDOCS scoring system to overestimate the measurements.

Conclusion

EBS is a form of admission triage system that ensures that ED patients have

admission priority over polyclinic patients and is intended to prevent overcrowding.

In a hospital where total bed numbers are inadequate, the EBS can be used for the

purpose of accelerating admission to hospital from the ED in order to reduce ED

overcrowding. Further investigation into the EBS and its practicality and application

in different hospitals is need.

Conflict of Interest

The authors declare that there is no potential conflicts of interest.

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Footnotes
Published online: June 04, 2014

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