Access block and emergency department overcrowding

Access block affecting the emergency department (ED), also known as boarding in the United States and Canada, can be described as a phenomenon comprising almost all the challenges in the world of modern EDs. We use the analogy of parallel universes to illustrate both the complexity and the severity of the problem. In the world of physics, many attempts have been made to create a mathematical solution that can answer the more basic questions about physical phenomena in the universe. This has been known as ‘Theory of Everything’. Albert Einstein spent 30 years of his life trying to solve this ‘Theory of Everything’, but failed [1].


Introduction
Access block aff ecting the emergency department (ED), also known as boarding in the United States and Canada, can be described as a phenomenon comprising almost all the challenges in the world of modern EDs. We use the analogy of parallel universes to illustrate both the complexity and the severity of the problem. In the world of physics, many attempts have been made to create a mathematical solution that can answer the more basic questions about physical phenomena in the universe. Th is has been known as 'Th eory of Everything' . Albert Einstein spent 30 years of his life trying to solve this 'Th eory of Everything' , but failed [1].
In the parallel universe of emergency medicine, access block, or delays in admission of patients to hospital inpatient areas from EDs, can be described as a whole system problem, the equivalent to the 'Th eory of Everything' . It remains a fundamental challenge, prompting comments such as: "Access Block and ED overcrowding have created a dynamic tension and the future of emergency medicine will be determined by the resolution of this confl ict" [2].
Despite access block and overcrowding in EDs being redefi ned, investigated and managed in multiple ways, it is far from being resolved [3,4]. Th is chapter summarizes the evidence from access block studies, exploring hospital, patient or medical interventions to reduce the impact of access block in terms of ambulance diversion, impaired access to emergency care, compromised clinical care, prolonged pain and suff ering as well as increased comorbidity and mortality associated with prolonged ED length of stay.
According to the Australasian College for Emergency Medicine (ACEM) access block is defi ned as "the situation where patients are unable to gain access to appropriate hospital beds within a reasonable amount of time, no greater than 8 hours" and 'overcrowding' refers to "the situation where ED function is impeded by the number of patients waiting to be seen, undergoing assessment and treatment, or waiting for departure, exceeding the physical or staffi ng capacity of the department" [5,6].
Access block has been linked to increased ED waiting time for medical care and leads to ED overcrowding. Th is overcrowding is generally accepted as a reason for decreased effi ciency and quality of care, and has also been linked to an increased incidence of adverse events [5,6]. It has been indicated that the 'Th eory of Every thing' has some fundamental problems [1]. Access block is also full of them. Th e fi rst problem is that most inter ventions produced to date have had some positive eff ects, although not necessarily on access block itself; however, they have been of short duration or have had limited or short term impact [7].
In the last decade, the UK reduced the acceptable waiting time for admission to hospital from the ED to four hours. Th is is known as the 'Four-Hour Target' , where 98% of patients must be seen and treated within four hours. It has produced signifi cant eff ects (both positive and negative). In Australia and New Zealand, the positive eff ect generated in the UK prompted the New Zealand government to implement a similar version -or a 'six-hour target' . In Australia, the State of Western Australia decided to implement the 'four hour target' and its implementation is in the fi nal stages. Th e South Australian health system is also in the process of implementing it. In relation to the negative eff ect, in the UK it has been reported that the 'four hour target' has been overused in an infl exible way by some hospitals. A Mid-Staff ordshire Trust report claimed that many patients died because of substandard care driven by the Trust management's wish to achieve Key Performance Indicators (KPIs) at any cost. Th is report has been tabled in the British parliament and the continuation of this policy has been re-considered by the new UK government [8,9]. However, the dilemma remains -is the four or six hour rule going to achieve its purpose?

Access block and emergency department overcrowding
Th e second problem is that access block has been described as a disease where the symptoms can be managed but the fundamental problem remains as yet unsolved [10].
Th e third problem is that access block is frequently associated with bed capacity and there are studies confi rming that hospital wards cannot be run at around 100% occupancy for long without considerable risk to patients as a result of delayed admission from the ED [11,12]. Most hospitals are run at full capacity and the problem is exacerbated by signifi cant pressures in health care, such as natural events (earthquakes, fl u pandemics, fl oods, bushfi res, etc.) or long waiting lists for elective surgery. It has been demonstrated that a fi nite-capacity system with variable demand cannot sustain both full utilization and full availability. A single level of ideal or safe occupancy suitable for all situations is a simplistic interpretation and application of the underlying science [12]. Th erefore, specifi c studies and actions are necessary to understand and deal with the problems of long waiting lists and access block in any given health care facility [12].

Magnitude of the problem
Recent literature reviews have demonstrated that most authors agree on three things [7,[13][14][15]: A. the problem is getting worse B. it is associated with poor health outcomes, and C. there are mainly three levels or factors associated with the problem, namely patient centered, hospital/system and clinical factors In relation to patient-centered factors, we are interested in understanding the operation of EDs and how this is impacted by access block and overcrowding, and the resulting eff ects on patients and staff . To do so we need to identify clinical/system factors, and which interactions may be infl uenced across departments, such as EDs, medical and surgical wards, intensive care units (ICUs), operating rooms, radiology departments and ambulance services.
It has been confi rmed that in Australia, the ED rate of presentation per 1,000 population increased by 35% between 2003 and 2008. Th ere were 1.98 million more presentations to Australian EDs in 2006-2007 (6.7 million) compared to the 2005-2006 fi nancial year (4.8 million) [7]. As a result of the increased demand and co-incident bed shortages, occupancy rates in most hospitals were greater than 85%, which has been considered the maximum level for effi ciency [6,[11][12][13][14][15]].

Hospital and system factors
In order to understand the complexity of the problem, we need to understand the fl ow on eff ect of access block on EDs and the cascading eff ect on other services.

Policy interventions
Easy answers are elusive (Fig. 1). Th e literature has identifi ed multiple policy interventions that have temporarily reduced the impact of access block and ED crowding. However, one of the challenges is to identify which interventions have been implemented and how they have aff ected specifi c areas, namely EDs, ambulance services, radiology, operating rooms, medical and/or surgical wards, and ICUs.
Th ere is strong evidence suggesting that initiatives to avoid or reduce the duration of hospital admission such as transit lounges, observation wards, multidisciplinary team interventions, additional ED staff and rescheduling of some services have produced positive eff ects, while ED expansion on its own has not been demonstrated to have a signifi cant eff ect on hospital diversion nor length of stay [16][17][18][19][20][21].
Many hospitals have reported that, by increasing staff capacity, they have been able to reduce ED length of stay [22]. In addition, other initiatives have combined multiple strategies to avoid admission such as transit lounges, short stay wards, and transit bays with alternatives to admission such as fast track and ambulance diversion [16,[23][24][25][26][27]. Other initiatives have transcended from the ED to other services. For example, it has been found that interventions initiated by nurses, such as nurse initiated X-ray services improve patient satisfaction, without impact on access block or ED crowding. Mental health patients can benefi t from the co-location of psychiatric emergency services within the ED, by the earlier delivery of specialist mental health care [28][29][30].
In a recent literature review, it was confi rmed that at least 62% of interventions reporting strategies to manage existing resources, had at least one positive eff ect on diff erent parts of the health system [7]. Hospital restruc tur ing has also been found to have a positive eff ect in Canada [31]. However, not all interventions have had the same eff ect. Access to general practitioner services within the hospital has had mixed results. It has been considered unsuccessful in some hospitals in Australia and New Zealand but has been reported eff ective in diverting patients from EDs in the Netherlands [32][33][34]. No Austra lasian study has reported any eff ect on the availability of co-located services at reducing access block or ED crowding, but they have shown that very low acuity patients consume a minimal part of ED resources and are cheaply and quickly treated at hospital EDs [7].
Individual initiatives, such as expanding the ED capacity from 24 to 54 beds, in isolation, without addressing other bottlenecks in the hospital, are ineff ective and insuffi cient to produce signifi cant changes on ambulance diversion or the proportion of patients who left without being seen [21].
In general, policies to reduce or control overcrowding have been associated with the majority of access block cases in Canada. Th ey are perceived by ED directors as largely ineff ective [35]. In the UK, policies such as early hospital discharge and the four hour target have had unintended consequences, such as the creation of incomplete episodes of care that have resulted in increases in the percentage of readmissions [8][9]13].

Emergency departments
Access block and consequent ED overcrowding constitute the greatest threat to quality emergency care. Inadequate hospital bed capacity and fl exibility, or lack of an available bed when it is needed, result in the delay of transfer of patients from ED to an appropriate in-hospital bed, particularly to medical and surgical wards as well as ICUs [5][6][7].
Th ere is evidence that ED length of stay targets such as the 'four hour target' can produce important changes in work practices, hospital and system processes, and discharge planning, leading to more effi cient use of resources and reducing ED overcrowding [41]. However, evidence also demonstrates that emphasis on time alone, rather than quality of patient care, can adversely aff ect patient safety and staff morale [8,9].

Ambulance service
Ambulance bypass or diversion is the situation where ambulances cannot deliver patients to the closest hospital as a result of overcrowding in that hospital. It has been identifi ed especially in urban areas as one of the more serious issues resulting from access block [7]. Access block and overcrowding have also resulted in extended delays either at the scene in the community or in transport time from the scene to hospital. Simple expansion of the ED does not have a signifi cant eff ect on ambulance diversion [21]; instead, ED length of stay increased [21]. In addition, the improvement in the proportion of patients who left the ED without being seen was minimal. Internet-accessible emergency department workload information may reduce ambulance diversion [27]. Th e

Ambulance
Increased ambulance holding time at the ED. Reduced ambulance response capacity Increased ambulance response times Increased ambulance delay

Operating Room
Increased time to definitive treatment for surgical cases with impact on outcome (e.g., #hip, acute abdomen) Delayed time seen in ED to surgery commence

Emergency Departments (EDs)
Reduced capacity and overcrowding, Increased waiting time Lower staff to patient ratio Increased risk of errors Less supervision by seniors

Radiology and Pathology
Increased delays to receive key diagnostic services Decreased capacity for radiology to process tests and results Conditions like stroke and acute abdomen may result in poorer outcome. Increased delay time from ED arrival to first radiology and arrival to CT for selected conditions

Medical/Surgical Wards and ICU
More patients being sent to 'outlier wards'? Wards less likely to deliver specialized care? Increased poor outcomes? Difficulties in measuring ward history information

Policy Interventions
Which policy interventions reduce the impact of access block on patient outcomes? ? main eff ects of access block on ambulance services include increased ambulance holding time at the ED, reduced ambulance response capacity, increased ambulance response times, increased ambulance delays, and increased mortality [38].

Radiology and pathology
Rapid access to diagnostic services from EDs is important [42]. It has been found that radiology and pathology tests initiated by nurses improve patient satisfaction [28,29]. Th ere is evidence of increased test ordering using these providers [43]. It has also been documented that EDs and inpatient units are facing challenges associated with the impact of access block and ED overcrowding on radiology and pathology. Increased demand for imaging can result in delays to receiving those services as well as errors in the production and processing of radiology orders [6,7]. Th e same has been reported for pathology services, resulting in poor health outcomes for certain conditions such as stroke and acute abdominal conditions [43,44].

Operating room
Access block can cause delays to defi nite treatment for surgical cases with adverse impact on outcome, such as hip fractures and acute abdominal conditions. Th is is often exacerbated by operating room closures during holiday periods such as Christmas and the New Year periods. In addition, access block may interrupt elective surgery which may have escalating eff ects on the whole system. Cancellation of elective surgery, for example, has been found to have an important eff ect on funding arrangements, hospital capacity and the way operating rooms are utilized [45].

Medical, surgical wards and the ICU
Pressure to admit patients more rapidly from the ED can result in patients being sent to 'outlier wards'; wards less likely to deliver specialized care. When bed occupancy rates are reduced, patient fl ow improves by allowing patient transfer to the wards, which, in turn, frees up EDs, so that patients from the waiting room or ambulance bay can be seen and processed, reducing ED length of stay, ambulance diversion and operating room cancellations [20,[46][47][48].

Potential solutions
It has been reported that the effi ciencies gained from successful implementation of national access targets, such as the 'four hour target' , may lead to a one off improvement in capacity and access to beds through improvement in processes, possibly the equivalent of 5-8% capacity [8,49]. Access targets may help our health systems deal more eff ectively with the long-term growth in demand for acute beds of about 2-4% per year but cannot be the only solution. Increased physical bed capacity in hospitals in order to reduce bed occupancy levels is required.
Out of hospital, demand management strategies and improved community support are also necessary. In particular, the demand associated with aged care and mental health must be addressed as a matter of urgency so that suffi cient resources are available for these patients to be treated in the community, thus avoiding acute hospital admission where appropriate.
Accurate audit or research data for the benefi ts/risks of introducing these targets are limited. Evaluation, continuous audit, and transparent dissemination of results are essential to allow fl exible changes in response to outcomes at the local level, and across the system. Consideration of each hospital's diff ering circumstances, for example, local populations and disease severity, availability of specialized resources or staffi ng models, must guide local implementation. Rigorous and independent monitoring at the national level must be mandatory to safeguard quality clinical care, and to ensure optimal use of health system resources [49].
In summary, the patients most aff ected by access block and overcrowding are those who, because of their medical condition require unplanned admission to hospital [6,7,10,[13][14][15]. Th e reasons for some patient groups being more aff ected by access block are multi factorial and complex. Deleterious eff ects as a result of overcrowding and access block have been found in trauma patients [39], and include: Increased delays in transfer to ICU [46][47][48]; delays in pain treatment [6,7]; increased numbers of patients who did not wait for treatment [36]; increase in patient adverse events [37]; and increased mortality [38,39].
Additional resources will be required for redesigning current processes, improving access to diagnostic and other support services and making eff ective use of hospital infrastructure over extended hours. In particular, appropriate, and improved, staffi ng of EDs, general wards and diagnostic and support services is necessary to ensure prompt, timely and safe care for patients, 24 hours per day, every day [49].
Resources must support the continued ability of the ED, hospital and community providers to fulfi ll clinical education, training and supervisory obligations in accordance with national professional guidelines and standards [49]. In relation to the evidence about what works and what does not work, the majority of the evidence on interventions comes from single hospital rather than multicenter studies. In order to improve the type and success of access block interventions more multilevel studies are needed instead of retrospective or observational/descriptive studies.

Conclusion
If we considered access block as a disease then we would be forced to treat only some of the symptoms, but the fundamental condition would remain unaff ected [7,10]. As indicated above, many interventions have been partially successful, but as long as the fundamental causes remain, the symptoms sooner or later will re-emerge [7].
In large EDs, 40% or more of staff time is spent caring for patients who are waiting for a bed, rather than looking after new emergency patients [50]. An emphasis on what is clinically appropriate for patients underpins success in improving access to care. In relation to potential solutions, in addition to adequate mental health and transitional care beds (fl exible beds) there is a need for robust, long-term data collection and system dynamic analysis [42]. Finally, transparency and free access to data must be made available to those who understand the health care system and can provide possible ways to improve the system. Th is must include researchers and clinicians as well as policy makers and bureaucrats.