| Abstract |
Overcrowding in Emergency Departments (EDs) is a global public health problem that affects negatively their performance. There are many causes of overcrowding, among those the most crucial are the continuously increasing number of ED’s visits, the delay in hospital admission of the patients bottle neck and the general mismatch between supply and demand for health care services1,3. Other causes of overcrowding are broad spectrum of the patients (acidity and complexity of their condition), the aging of the population, the inadequacy of Primary Care Health services, the staff shortage, the delay in the consultation from other specialties, the delay in the turnover of the laboratory tests, the management of the critically ill patients and their long stay in the ED waiting for ICU admission delay or as inpatient in the different department of the hospital 4,5. The consequences of overcrowding are serious, such as increased waiting times and length of stay into the ED, increased morbidity and mortality, increased incidence of diagnostic and treatment errors, decreased patient and staff satisfaction, aggression against the staff and patients leaving without being seen by a doctor LWBS 3,5. In our country, the same reasons for overcrowding not only stands but are more exaggerated due to the coexistence of all the aforementioned factors and the unaccepted model of the periodically being on call rota of the hospitals in bigger cities. The overcrowding of the Greek EDs, although obviously seen as a daily icon has not yet been meticulously studied and evaluated so as to be able to make appropriate proposals for appropriate taken interventions to solve or at least improve and ameliorate this problem 2.
The Aim: This study was conducted to record and assess the degree of overcrowding in ED of a tertiary hospital in Heraklion, Crete, to investigate the causes of its occurrence in order to suggest, design and probably implement the intervention needed to address the problem. As a second target of this study is compare our results to similar studies and to use it as a base line for future evaluation of our ED’s performance. Material and Method: This is a prospective, descriptive recording study based on the clinical features of the patients that visited our ED from June 14 to June 30, 2018, in order to investigate the existence, extent and etiological factors of the overcrowding. Data collection was made from the Med-Line electronic database of PAGNI. , and from the individual patient cards in the ED. Data collection included: the demographic characteristics of the patients, the time and rates of the patient flow, the place of the first medical evaluation of the patients, the waiting times in every point of medical assessment , the total ED length of stay , the acidity of the patients based on the ESI scale, the number and timing of ED arrivals, the percentage of the patient transferred by the EMS, patients who left without being seen (LWBS) or left against medical advice (LAMA) and patients who underwent mechanical ventilation into the ED. For most of the above parameters , correlation was made with the acidity levels and the waiting and staying times in the ED. Finally nursing interventions and the number of laboratory and radiology examinations were recorded and evaluated.
Results: 4.775 patients visited the Emergency Department of PAGNI during the study period, an average number of visits, 530.5 patients / 24 hours. 52% were men and 48% women, mostly Greeks. The mean age was 42.65 years. Most of them (50.77%) belong to the age group from 21 to 60 years old. Elderly patients consisted the 27.28% of the visits.
The average flow rate towards the medical clinic of the first reception was 4.04 minutes at peak hours (8.00 - 24.00). The 61% of the patients were totally managed in the clinic of the first medical evaluation with the rest 39% needed to be referred for further consultation by other specialists. The median waiting time for the time of the first evaluation was 23.02 (SD ± 21.8, IQR 0-199) minutes, with longer median times for Triage (mean 20.50, SD ± 15.5, IQR 0 -92 minutes) and in Pediatric (Mean 41.72 SD ± 34.7, IQR 0-199 minutes). The mean waiting time in referral medicals offices for consultation by a specialist was 47.00 minutes (SD ± 39.87, IQR 0-379), with longer times recorded for Neurologists (Mean 105.00, SD ± 83.71 , IQR 42-200 minutes) and Internists (Mean 78.08 SD ± 59.66, IQR 0-379 minutes).
The total length of stay in EDF for patients who was discharged was 2.17 (SD ± 2.23, IQR 0.0-20.3) hours and for patients admitted to the hospital was 2.28 (SD ± 214, IQR 0, 0-13, 24) hours. The longer times encountered for the patients admitted to the Neurology Clinic (mean 4,10 hours), Internal Medicine (mean 4,00 hours) and the Cardiology Clinic (mean 3,15 hours).
High acuity cases (ESI - 1 and ESI - 2) accounted for 8.42% of the cases. 45.5% of patients were of mean acuity (ESI 3), 31.47% were of low acuity (ESI 4), and 14.54% had no urgent health problem (ESI 5).
17.8% (850 patients) of visitors in ED were admitted to hospital, Short Stay Unit (SSU) of the ED included. The largest proportion of patients, 30.6%, were admitted into the Internal Medicine Section of the hospital. A total of 4,2% of all ED visits and 24,2% of hospital admissions from the ED were initially admitted into the Short Stay Unit. 52.2% of SSU patients eventually admitted to clinics, with the rest 47.8% being discharged.
11.76% of all visits to the ED were transferred by the EMS. The 76% of them were patients with pathological conditions and 24% were trauma patients. The acuity levels of patients transferred by the ambulances were: ESI - 1, 5.7%, ESI - 2, 64.2% and ESI - 3, 30.1%. The mean time of hand over of these patients was 1.05 minutes (SD ± 1.55, IQR 0.2-2.4), and the mean waiting time for the initial medical evaluation was 10.35 minutes (SD 13.4, IQR 0.0-90). A percentage of 2.6% of patients left without being seen doctor (LWBS) and 2.5% of patients left against medical advice (LAMA),. The mean time before the departure of patients with LWBS was 49.74 minutes (SD ± 30.55, IQR 4.0-155.0), while the mean length of stay of patients with LAMA was 160 , 55 minutes (SD ± 132.89, IQR 15.0-736.0).
26 patients, underwent mechanical ventilation during the study period, 17 invasive and 9 non-invasive ventilation (NIV). The 24-hour mortality was 19.23%. The mean time of stay in the ED of the patients received invasive ventilation was 2.04 hours (SD ± 2.20, IQR 0.55-8.50) and for those in non-invasive ventilation were 2.08 hours (SD ± 2.11, IQR 0 , 55-4, 10).
A number of 34,626 laboratory tests were done (7,25 examinations per patient during the initial evaluation and 11,5 examinations per patient were a consultation were needed. 3,339 radiology examinations (X-rays, USs, CTs, Scans), corresponding to 0,7 examinations per patient and 3,039 nursing interventions were made for the 63.64% of the patients.
Conclusions: Our results showed an increased influx of patients, disproportionately high to the population of the area and the capacity of the ED and of the hospital. Low equity patients numbered a significant % of the visits, and a high number of interventions and laboratory exams performed. A high % of patients could be managed in Primary care (PC) facilities. Waiting times for examinations at the medical’s offices, and the length of stay in the ED, is rather prolonged. It is mainly due to increased inflows of patients and to delay to hospital admission but also to an extent to the organization and performance of ED itself. The role of the SSU in ED offers an important service for admitted and non eventually admitted into the hospital patients. Multi-level corrective actions have to be taken in order to improve the total performance of the department and to reduce the phenomenon of overcrowding. At the same time, appropriate institutional and administrative measures should be taken at all levels of health services to alleviate the problem and the effectiveness of care.
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