A Q & m 0 5 10 15 20 25 30 35 40 45 50 55 60 F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F S SMTWT F ED Overcrowding: A Global Concern Reaching Us Hossam Elamir, [1,2] Abeer G. Dossokey, [1] Amal T. Mohamed, [1] & Lea Martinez [1] [1] Department of Quality and Accreditation, Mubarak Al-Kabeer Hospital, MOH [2] MSc in Healthcare Management, Royal College of Surgeons in Ireland a b 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Waing me before observaon Waing me before boold collecon Time to receive lab report Time to be seen by ED doctor Time to review blood report by ED doctor Time to have radiology invesgaon done Time to receive radiology report Time to review radiology report by ED doctor Time to have paent seen by medical doctor Waing me before boold collecon Time to receive lab report Time to review blood report by medical doctor Time to have radiology invesgaon done Time to receive radiology report Time to discharge/ shiſt paent to medical wards aſter Dr order Total me spent in ED ll admission/discharge 0:10 0:33 1:22 0:01 1:45 0:12 0:00 2:07 0:25 1:45 1:50 0:55 2:50 0:00 0:15 12:50 0:38 0:10 0:15 0:35 0:10 0:45 1:40 0:00 0:40 0:10 4:53 0:13 0:05 1:00 0:05 1:00 4:25 6:43 0:05 0:05 2:20 0:10 0:05 0:00 0:05 0:17 1:59 2:50 0:30 0:10 1:15 1:55 0:30 0:30 0:25 1:35 0:05 0:15 6:25 0:10 0:05 0:55 0:10 0:40 0:45 0:05 0:25 1:15 1:00 6:40 0:42 0:20 0:25 0:30 0:50 0:20 0:00 0:30 0:07 3:47 0:10 0:05 3:40 0:45 0:10 0:05 0:05 1:20 0:30 0:25 8:35 0:20 0:03 0:57 1:10 0:10 1:50 0:15 0:05 0:16 1:44 4:35 0:20 0:05 0:50 1:25 0:30 0:25 1:05 5:55 0:15 0:05 2:50 1:50 0:05 0:30 0:05 1:10 0:48 0:15 2:05 0:15 6:55 0:15 0:05 1:15 0:15 0:10 0:10 0:05 0:00 1:58 2:10 6:35 0:20 0:30 2:30 0:05 0:00 0:20 0:15 0:15 0:45 1:10 6:30 0:15 0:10 0:50 0:10 0:15 0:10 0:00 0:50 1:35 1:10 1:20 0:25 0:50 4:20 12:35 0:25 0:20 1:10 0:15 0:00 0:35 0:45 3:45 0:10 0:10 0:40 0:55 0:05 0:10 1:40 0:05 0:45 2:20 0:05 0:25 0:14 4:24 0:25 0:30 1:50 0:25 1:20 0:06 0:04 0:05 0:25 4:55 0:20 0:10 2:00 0:10 0:10 1:40 0:30 0:30 1:00 4:30 0:20 0:10 2:05 2:15 0:15 0:10 2:55 0:30 0:05 2:25 0:25 0:40 0:10 2:05 7:50 0:30 0:05 1:35 0:15 0:05 1:15 0:25 0:05 0:35 0:13 7:10 Case No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 I. Background Emergency Department (ED) overcrowding (OC) is defined as a situation where the demand for services exceeds the capacity of the department to provide them in a high quality and timely manner. [1] EDOC is associated with increased ED Length of Stay (LOS) of some patients beyond the accepted limit that varies from above 4 hours in UK to above 8 hours in Australia. [2] Both –EDOC and increased EDLOS- are key global issues for more than 20 years, as they have serious clinical, quality, safety and financial repercussions. [1,2] ED staff of the general hospitals in Kuwait and ED patients are reporting a progressively increased EDLOS and EDOC. No measurements have been done to assess the situation. On Sunday 26/1/2014, there were 33 patients waiting to be shifted to inpatient after they had been admitted. According to Heads of Emergency and Medical Department, this was a recurrent problem manifested every Sunday of Nov., Dec., 2013 and Jan., 2014. Moreover, it was reported many times to have patients in ED setting on wheelchairs or lying in trolleys (Fig. 1). Out of those 22 observed patients (Fig. 2), 10 patients stayed less than 5 hours in the ED (the greens), 7 patients stayed between 5 to 7 hours (the yellows) and 5 patients stayed more than 7 hours (the reds). Two patients stayed more than 12 hours and this was retrieved from patient records and ED staff observation records. A multidisciplinary team was formed to map the patient journey in ED. The team selected a day from 7 am till 7 pm to collect data and calculate wait times. ED nurses were requested to observe and register timing of the steps using a data collection form. During that 12 hour period, 22 patients were observed. The selection was based on Willoughby et al.’s [3] strategy to overcome the infeasibility of documenting all ED visits, so only the apparently more acute patients were observed. Fig. 1: The Overcrowded ED Room Fig. 4: No of Daily Discharges from Medical Wards (1/11/2013 - 31/1/2014) Fig. 2: Waits Time and Length of Stay in ED Fig. 3: Patient Wasted Time in Waits Compared to Services Time III. Conclusions IV. References II. Case Summary a. Mapping of 8:25 hrs patient stay in ED observation b. Aggregation of non-value added waits (white) vs. added-value services (coloured). Further mapping of case number (8) revealed that around 78% of the total time of the patient at the observation room was waits, with no value added (Fig. 3). Moreover, the team listed the possible causes of ED overcrowding and increased ED LOS, where the most important cause was admission blockage due to unavailability of inpatient beds. [1] The team retrieved the number of daily discharges from Medical department to find out a very peculiar cyclic pattern of daily discharges (Fig. 4). Every week there were two peaks for discharges, Sundays and Thursdays which are before and after weekends. This is why the ED is congested with waiting to be admitted patients every Sunday. We would like to acknowledge the help provided by Prof. Jane Griffiths, Director of Nursing, Rashid hospital , Dubai Health Authority For further information contact: Dr. Hossam Elamir, Head of Quality & Accreditation Department, MKH, MOH, Kuwait Mobile: 00965-65198442 - E mail: [email protected] Linkedin URL: kw.linkedin.com/pub/hossam-elamir/b2/97b/296 1. Affleck A, Parks P, Drummond A, Rowe BH, Ovens HJ. Emergency department overcrowding and access block. CJEM. 013;15(6):359–70. 2. Horwitz LI, Green J, Bradley EH. US Emergency Department Performance on Wait Time and Length of Visit. Annals of Emergency Medicine. 2010;55(2):133–41. 3. Willoughby KA, Chan BTB, Strenger M. Achieving wait time reduction in the emergency department. Leadership in Health Services. 2010 Oct 5;23(4):304–19. This 12 hour observation revealed alarming signs. More than one fifth of the sample (22%) had long EDLOS and most of the time spent was waits, and Access Block to inpatient wards was the primary cause of prolonged EDLOS and EDOC every Sunday. This variation in practice should be corrected by providing Accounting department staff all through the week and discharge rounds in weekends. A national-wide measurement project should be considered to define the exact problem volume, its impact and identify its causes. Setting ED performance indicators for clinical and service times together with the whole EDLOS might be helpful to track progression. [2] V. Acknowledgement & Contacts