Emergency department crowding is a hospital-wide problem

Gillings School researchers lead efforts to find solutions

July 30, 2019

Overcrowded hospital emergency departments (ED) can have negative consequences on patient health and hospital performance, but when it comes to solutions to ease gridlock in the ED, one size does not fit all.

Dr. Amir Alishahi

New research from Amir Alishahi, MD, PhD, a recent doctoral graduate from the Department of Health Policy and Management at the UNC Gillings School of Global Public Health, finds that without hospital-wide interventions and a culture that recognizes ED overcrowding as a hospital-wide issue, most efforts will not have a significant impact on the problem.

Alishahi is lead author of two new papers on the topic: “Association between adopting emergency department crowding interventions and emergency departments’ core performance measures,” published in the April issue of American Journal of Emergency Medicine, and “What is full capacity protocol, and how is it implemented successfully?” published July 18 in Implementation Science.

Other Gillings School faculty on these projects are Justin Trogdon, PhD, Bruce Fried, PhD, and Christopher Shea, PhD, all associate professors of health policy and management, and Sarah Birken, PhD, assistant professor of health policy and management.

In the first paper, Alishahi and his team investigated the association between 20 different ED crowding interventions — ranging from bedside registration and physician-based triage to hospital-level interventions — and five core ED performance measures: wait time, board time, ED length-of-stay for discharged patients and for admitted patients, and rate of leaving without being seen.

“Understanding the impact of ED crowding on hospital performance measures is important because, in a highly competitive environment with limited resources, hospital leaders and policy-makers are challenged to select interventions with the greatest likelihood of effectively addressing hospital and health system problems,” says Alishahi.

The researchers analyzed data from 1.18 billion ED visits in the United States between 2007 and 2015. They found that the number of visits has increased by about 24% in that time — four times faster than U.S. population growth. Another notable finding was that, in 2014, Medicaid passed private insurance as the single most frequent payer for ED visits for the first time in U.S. history.

Though both waiting time and the percentage of patients who left the ED without being seen significantly decreased during this time period, patients’ entire lengths of stay actually increased. The paper suggests this occurs when hospitals fail to strategically adopt the ED crowding interventions that are most likely to improve patient flow processes in their hospitals, such as full capacity protocol (FCP).

For the second project, therefore, Alishahi’s team studied the adoption and implementation of FCP, an ED crowding intervention determined by the previous study to be one of the most effective. FCP transfers select patients (who have been admitted to the hospital but, due to a lack of available beds on the inpatient units, are still boarding in ED hallways) to board in the inpatient unit hallways instead.

“The idea behind FCP is that once the patient is in the hallway of an inpatient unit, in view of the nurses, doctors and staff, a room will be found faster, beds get cleaned quicker and the entire system works more efficiently,” says Alishahi.

FCP has since evolved from this original concept of transferring patients from hallway to hallway into a complex, hospital-wide intervention with several components and multiple levels. However, despite the protocol’s relative success, many hospitals face barriers to implementation such as lack of leadership support and commitment, resistance of inpatient nurses, impacts of external regulations and policies (e.g., fire marshal regulations) and, most importantly, a hospital culture that perceives the ED crowding as solely an ED problem that is unrelated to the entire system.

“No matter which interventions hospitals implement, without a culture that understands ED crowding requires hospital-wide solutions, all the steps we take to address the crowding are just temporary remedies,” says Alishahi.

Contact the Gillings School of Global Public Health communications team at sphcomm@listserv.unc.edu.