Transcript (EDs) overcrowding as perceived by Health care providers and

‫بسم هللا الرحمن الرحيم‬
Causes and effects of Emergency Departments (EDs)
overcrowding as perceived by Health care providers and
consumers
Nagwa A Reda, DNs – Assistant professor, Critical Nursing Department
Fatma M Baddar, DNs – Lecturer, Nursing Administration Department
Faculty of Nursing
Alexandria University
THE NEW EGYPTIAN JOURNAL OF MEDICINE
Vol. 35; No. (3) 1st September 2006 p. 163 - 175
Introduction
• Emergency
departments
(EDs)
are
responsible for dealing with a large number
of patients who pass through them, and
they do not restrict themselves to the
treatment of specific medical specialties.
• This creates significant problems related to
overcrowding, associated with extended
waiting period, increasing acuity and delay in
the initiation of needed emergency care.
• As a result, patient suffers from undue
prolonged
pain,
inconvenience,
and poor outcomes.
frustration,
•
Overcrowding is considered a situation in
which demand for service exceeds the ability
to provide care within a reasonable time,
causing physicians and nurses to feel too
rushed to provide quality care.
• The phenomenon of emergency departments
EDs overcrowding cannot be attributed to
any single factor, but instead appears to be
a
product
of
complex
causal
relations,
encompassing multifactor.
•
As direct consequence of these causes or
factors
EDs
overcrowding
has
numerous
negative effects on the quality of patient
care,
health
environment.
care
providers
and
ED
Aim of the study
• determine the causes, and effects of EDs
overcrowding as perceived by the health care
providers and consumers ,and
•
to propose potential solutions to overcome
the negative effects of EDs overcrowding .
Materials and Methods
Materials
Design:
• Descriptive analytical research design.
Setting:
• This study was carried out at the
Emergency
departments
EDs
of
Alexandria
University
Hospitals
namely: Main University Hospital, ElChatby Maternity University Hospital
and El-Chatby Pediatrics University
Hospital.
Subjects:
• A convenient sample of Medical staff that
are involved in direct patient care in EDs
(N=13) in the previously mentioned hospitals,
• all the head nurses of EDs (N= 3),
•
representative sample of Nursing staff
(N= 55),
• and available sample of EDs conscious
patients who are able to communicate (N=10)
Tool:
• EDs
overcrowding
questionnaire
was
developed by the researchers based on
reviewing the related literatures, it
included four parts;
• Part
I:
demographic
used
to
collect
characteristics
study ‘ subjects.
of
the
the
• Part
II:
used
to
assess
subjects'
perceptions about the causes of EDs
overcrowding, it included 26 causes that
are related to four main categories
namely:
Manpower,
resources
facilities, patients, and work system
and
• Part III: used to assess
perceptions of effects of
overcrowding, it included
covered the three dimensions
the following:
subjects'
the EDs
16 items
related to
• Medical and Nursing
included (7 items).
personnel
that
• Quality of patient
included (7 items).
services
that
• EDs
environment
(2 items).
that
included
• Part IV: used to assess subjects'
perceptions of the proposed potential
solutions
to
EDs
included (20 items).
overcrowding,
it
Methods
Data Collection:
• The questionnaire interview method
was used with identified subjects
individually to collect the data.
After completing the demographic data,
the subjects were asked to identify and
rate the causes of the EDs overcrowding
according
to
their
type,
as
they
perceived. A three – point likert scale
was used ranging from (1) minor cause to
(3) major cause. (Part I, part II of the
tool).
• Then Respondents were asked to
identify the effects of the EDs
overcrowding and rated on a threepoint likert scale ranging from (3) high
effect to (1) low effect (part III).
• After that respondents were asked to
identify
and
rate
the
potential
solutions to EDs overcrowding on a
three- points likert scale ranging from
(3) highly agree to (1) slightly agree
(part IV).
Statistical analysis:
Data obtained from this study were stored and
coded with the aid of computer. Since there
were a large number of variables (26) under
causes, (16) under effects and (20) under
proposed
potential
solutions),
finding
relationships among all of these variables are
difficult, therefore, it was decided to use
factor analysis, which is suitable to reduce the
amount of variables to a smaller number of
related variables called factors.
The data were analyzed by using SPSS
version 13.0 and the method of extraction
used was principal component analysis and
the rotation was done by the Varimax
method with Kaiser Normalization.
Data
tabulated
of
the
and
obtained
presented
results
in
were
frequency
distribution tables. Findings were presented in
numbers
and
between
causes
percentages.
and
Relationship
effects
of
EDs
overcrowding and between effects and the
solutions of EDs overcrowding were carried
out
using
Chi-square
(χ2).
The
level
of
significance selected for the study was P=
0.05.
Results
•Factor analysis statistical test reduced the
26 variables of causes into 5 factors only
arranged according to their factor loading in
descending order (appendix1-a)
Appendix (1-a): Factor Loading of Causes of EDs Overcrowding)
Component (Factors)
Causes (Variables)
1
2
3
4
5
16- Limited availability of non-nursing staff
0.859
-0.019
-0.018
0.057
0.077
15- Ancillary services not same hours as ED
0.769
-0.022
-0.040
-0.087
-0.111
18- Shortage of physical plant space
0.676
0.391
-0.315
-0.255
0.148
19- No system for supervising and evaluating work
at ED
0.621
0.093
-0.065
0.184
0.300
20- Lack of availability of ground ambulance to
transfer patient
0.592
0.186
-0.126
0.137
-0.089
17- Shortage of on-call specialist consultants
0.568
0.366
0.159
-0.246
0.027
21- Requirement to find professional nurse to
accompany patient while transfer
0.515
0.173
0.005
0.314
-0.070
12- Lack of 24 hour lab testing
0.439
-0.040
0.168
-0.020
-0.283
4- Drug abuse, homelessness, ...
0.421
0.316
-0.066
0.145
0.373
24- Increased documentation requirements
0.305
0.209
-0.142
0.228
0.195
1-Lack of beds
0.110
0.744
-0.246
-0.002
0.011
25- Shortage of administrative/ clerical support
-0.225
-0.661
0.396
0.255
0.125
2- Increase length of stay
0.006
0.660
-0.075
0.181
-0.002
6- Shortage of nurses and physicians
0.353
0.608
-0.213
0.195
0.206
26- Lack of security personnel
-0.310
-0.602
0.496
0.054
0.070
3- Increase complexity and acuity
-0.019
0.594
-0.033
0.330
-0.099
14- Delays in radiology and laboratory services
0.417
0.560
0.168
-0.249
-0.029
10- Large volumes of patients with not urgent
problems
0.075
0.430
-0.194
-0.366
0.164
7- Incompetence of trained nurses
-0.044
-0.023
0.869
0.031
0.032
9- Incompetence of trained physicians
-0.044
-0.150
0.845
0.039
-0.018
8- High nursing staff turnover
0.100
-0.120
0.821
0.088
0.227
11- Lack of advanced diagnostic testing
0.349
0.334
-0.436
0.068
-0.014
22- Absence of local standards to guide planning
and delivery of ED services
0.120
0.017
0.195
0.841
-0.076
23- Limited resources of ED
0.118
0.115
-0.069
0.757
0.063
5- Increasing frequency of day surgery
-0.082
-0.124
0.048
0.034
0.851
13- Unavailability of operating room time
0.036
0.021
0.371
-0.143
0.732
Regarding Causes of the ED overcrowding, it
classified into four main categories namely:
•Manpower
• patients
•resources and facilities and
•work system
Fishbone diagram (Cause and effect)
Manpower
Limited availability of non nursing staff
shortage of on-call specialty consultants
requirement to find professional nurse
to accompany the patients while transfer
shortage of administrative/clerical support
shortage of nurses and physicians
lack of security personnel
incompetence of physicians and nurses for ED care
high nursing staff turnover
ED Overcrowding
drug abuse
homelessness
domestic violence
increased complexity and acuity of patients
presence of company with patients
presence of large number of patients without urgent problems
Patient
Fishbone diagram (Cause and effect)
Resources
and facilities
shortage of physical plant space
lack of availability of ground ambulance transportation
limited resources of ED in the form of medical apparatus
Lack of supplies and medications
unavailability of operating room time
ancillary services not same hours as ED
No system available for supervising and evaluating work
lack of availability of 24-hour laboratory tests
increased medical records documentation requirements
increase length of stay due to waiting for test
delay in the services provided by radiology, laboratory and
ancillary services
delay in treatment and prolonged patient stay in ED
Work system
ED Overcrowding
• Regarding
effects
of
the
ED
overcrowding, it was reduced also to
three
factors
from
the
original
sixteen effects and ranked according
to factor loading too. (appendix1-b)
Appendix (1-b) Factor Loading of Effects of EDs Overcrowding
Component (Factors)
Effects (Variables)
1
2
3
1(8)- Prolonged delays in treatment of pain and suffering
0.900
0.128
0.003
5(12)- Increased costs of emergency health service system
0.883
-0.033
0.054
6- I*inability to keep pace as a result of increasing
workload on nurses
0.862
0.143
0.162
7- Nursing staff have limited time for patient education
0.851
0.174
0.223
15- Outbreaks of infectious diseases
0.813
0.128
0.228
16- Increasing violence
0.804
0.191
0.190
7(14)- Interpersonal miscommunication because of
increased patients volume
0.769
0.235
-0.145
3(10)- Patient dissatisfaction as a result of increasing
waiting time
0.729
0.024
0.000
3- Increase medical errors and medico--legal risks
0.666
0.422
-0.430
4- Increase risk errors in providing patient care
0.644
0.513
-0.340
6(13)- Increase risk for traffic accidents and potentiality for
poor clinical patient's outcome
0.638
0.221
-0.217
5- Increase stress and dissatisfaction among ED nursing
staff
0.532
0.497
-0.503
1- Inadequate time for proper patient assessment
-0.042
0.878
0.160
2- Increase frustration and decrease medical staff morale
0.228
0.781
0.218
4(11)- Increased incidence of ambulance diversion leading
to increased transportation time
0.054
0.167
0.824
2(9)- Long waiting time for receiving services may place
patients at risk
0.446
0.253
0.682
The effects were covered three areas:
•
•
Quality of care that provided to patients
Health care providers' satisfaction and
• Working environment.
Quality of patient care
prolonged delays in the treatment of patient pain Increase medical errors and medico-legal risk
increasing incidence of ambulance diversion
increase risk for traffic accidents which place pt. at risk
increase costs of emergency health service system
poor clinical patient's outcome and patient dissatisfaction
negative effect on ED productivity
increasing workload on ED staff
inability to keep pace with demands for the services
inadequate time for proper patient assessment, diagnosis
and treatment
nursing staff has limited time to patient education 7
Interpersonal miscommunication
increase level of stress among ED staff and dissatisfaction
increase level of frustration and decrease staff morale
Health care providers
Fishbone diagram (Effect of ED Overcrowding)
Effect of ED Overcrowding
Work environment
outbreaks of infectious diseases
increasing
violence
Effect of ED Overcrowding
Fishbone diagram (Effect of ED Overcrowding)
Relationship between causes and effect of ED overcrowding
Manpower
Incompetence of trained nurses
*
Incompetence of trained physicians
High nursing staff turnover
• Inadequate time for proper
patient Assessment
Lack of advanced diagnostic testing
•
frustration and
Medical
And nursing staff moral
Resources and Facilities
Causes of factor 3
Effects of factor2
Relationship between causes and effect of ED overcrowding
Resources and Facilities
Limited resources of ED
•
*
incidence of ambulance
diversion lead to
transportation time
Absence of local standards to guide planning
and delivery of ED services
•long waiting time for receiving
services that place
patients at risk
Work system
Causes of factor 4
Effects of factor3
As regarding solutions, numerous
solutions have been proposed to
improve quality, efficiency of EDs
and alleviate overcrowding negative
effects.
•Factor analysis statistical test reduced the
20 variables of solutions into 4 factors only
arranged according to their factor loading in
descending order (appendix1-c)
Appendix (1-c) Factor Loading of Solutions of EDs Overcrowding
Component (factors)
Solutions (Variables)
1
2
3
4
3- Develop recruitment and retention initiatives
for emergency physicians and nurses
0.853
0.272
0.132
0.285
4- Review the need, desirability and
requirements of fast-track and observational
units for EDs
0.802
0.297
0.322
0.196
15- Expand training and education programs for
emergency physicians and nurses
0.572
0.378
0.394
0.445
2- Increase the supply of qualified emergency
nurse
0.543
0.270
0.441
0.393
13- Faster response from specialists for critically
ill for admission and surgery
0.538
0.423
0.423
0.275
7- Implementation of the emergency department
triage
0.536
0.411
0.403
0.426
Component (factors)
Solutions (Variables)
1
2
3
4
8- Implement real time emergency department
information system (EDIS)
0.276
0.761
0.319
0.302
20- Coordination with long term health facilities
and home health agencies to expedite
hospital discharges and follow up
0.395
0.693
0.226
0.301
6- Local waiting time standards for patients
admitted to ED need to be developed and
enforced
0.519
0.560
0.313
0.273
19- Create a short-stay observation unit and a
"transition team" to expedite care in ED
0.494
0.526
0.389
0.228
12- Increase accessibility to community and
primary health care
0.159
0.448
0.737
0.220
17- Adequate funding and resources for EDs
0.498
0.093
0.682
0.393
14- Expansion of long term care facilities
0.447
0.394
0.605
0.395
5- Further review of ambulance service provision
0.387
0.551
0.599
0.147
9- Increase access to immediate diagnostic
testing
0.256
0.540
0.591
0.381
10- Increase availability for laboratory and
diagnostic imaging services
0.249
0.522
0.536
0.455
18- Increase internal transportation services
0.322
0.205
0.306
0.832
11- Sufficient availability of support staff
0.188
0.497
0.244
0.749
1- Increase the capacity through establishing a
holding unit
0.575
0.276
0.177
0.639
16- Provide stretcher and other equipment to
deal with conditions requiring urgent
intervention
0.541
0.251
0.389
0.586
Relationship between effects and solutions
Work System
Develop recruitment and retention initiatives
for emergency physicians and nurses
Review the need, desirability and requirements of
fast-track and observational units for EDs
*
Implementation of the emergency department triage
Expand training and education programs
for emergency physicians and nurses
Increase the supply of qualified emergency nurse
Faster response from specialists for critically
ill for admission and surgery
Manpower
Fishbone diagram
Solutions of factor1
•Prolonged delays in pain treatment
•Increased costs of emergency
health services
•increasing workload on nurses
•Nursing staff have limited time for
patient education
•Outbreaks of infectious diseases
•Increasing violence
•Interpersonal miscommunication
•Patient dissatisfaction as a result
of increasing waiting time
•Increase medical errors and
medico--legal risks
•Increase risk errors in providing
patient care
•Increase risk for traffic accidents and
potentiality for poor clinical patient's
Outcome
•Increase stress and dissatisfaction
among ED nursing staff
Effects of factor 1
Relationship between Effects and Solutions
Manpower
*
Sufficient availability of support staff
Increase internal transportation services
Increase the capacity through establishing a holding unit
Provide stretcher and other equipment to deal with
conditions requiring urgent intervention
Resources and Facilities
Fishbone diagram
Solutions of factor 4
•Prolonged delays in pain treatment
•Increased costs of emergency
health services
•increasing workload on nurses
•Nursing staff have limited time for
patient education
•Outbreaks of infectious diseases
•Increasing violence
•Interpersonal miscommunication
•Patient dissatisfaction as a result
of increasing waiting time
•Increase medical errors and
medico--legal risks
•Increase risk errors in providing
patient care
•Increase risk for traffic accidents and
potentiality for poor clinical patient's
Outcome
•Increase stress and dissatisfaction
among ED nursing staff
Effects of factor 1
Relationship between effects and solutions
Work System
Develop recruitment and retention initiatives
for emergency physicians and nurses
Review the need, desirability and requirements of fasttrack and observational units for EDs
Implementation of the emergency department triage
Expand training and education programs for
emergency physicians and nurses
Increase the supply of qualified emergency nurse
*
•Inadequate time for proper
patient assessment
•Increase frustration and
decrease medical staff morale
Faster response from specialists for critically
ill for admission and surgery
Manpower
Fishbone diagram
Solutions of factor 1
Effects of factor 2
Relationship between Effects and Solutions
Work System
Implement real time emergency department
information system (EDIS)
Coordination with long term health facilities and
home health agencies to expedite hospital discharges
and follow up
*
Local waiting time standards for patients admitted
to ED need to be developed and enforced
•Increased incidence of
ambulance diversion leading to
Create a short-stay observation unit and a "transition
team" to expedite care in ED
increased transportation time
•Long waiting time for receiving
services may place patients at
risk
Resources and Facilities
Fishbone diagram
Solutions of factors 2
Effects of factors 3
Conclusion
The current study results revealed that
Causes
of
ED
overcrowdings
related
to
namely:
Manpower,
four
main
are
categories
resources
and
facilities, patients, and work system
itself
the effects were covered three areas:
quality
patients,
of
care
health
that
care
provided
to
provider's
satisfaction and working environment .
Recommendations
The public views ED overcrowding as a symptom of a
health care system crisis because it has numerous
negative consequences on the quality of patient care.
but it is the time for the restoration of the public
confidence in the emergency health care system
Because
the
problem
emergency
can
be
solved
if
health care providers are given
adequate opportunity to provide meaningful input to
potential solutions, and the government, hospitals and
emergency health care providers work cooperatively to
relegate ED gridlock to that of an historical anomaly.
And
thus
improve
quality,
efficiency
alleviate overcrowding negative effects.
of
EDs
and