Overcrowding in emergency rooms is a persistent problem caused by myths rather than reality. While it is often claimed that inappropriate or minor patients are the cause, evidence shows this is false. The true cause is a lack of overall hospital capacity. When capacity is increased, overcrowding decreases. Attempts to solve overcrowding through minor initiatives like phone lines or clinics do not work because they do not address the underlying lack of beds. Overcrowding has serious consequences for patient care and outcomes. Access block is avoidable when capacity is appropriately increased across the entire hospital system.

1. Access Block - the myth trial

2. Myth-quotes
• What a man believes upon grossly insufficient evidence is an index into
his desires - desires of which he himself is often unconscious. If a man is
offered a fact which goes against his instincts, he will scrutinize it closely,
and unless the evidence is overwhelming, he will refuse to believe it. If, on
the other hand, he is offered something which affords a reason for
acting in accordance to his instincts, he will accept it even on the
slightest evidence. The origin of myths is explained in this way.
• Bertrand Russell
• The great enemy of the truth is very often not the lie ; deliberate,
contrived and dishonest ,but the myth - persistent, persuasive and
unrealistic.
• JFK

3. • Creation myths :
– An ED problem due to GP type patients and inefficient EDs
• Outcomes / management myth :
– Poor patient outcomes are rare
– Poor outcomes have minimal consequences
therefore
– EDs are good places to store excess admitted patients
• Solution myths:
– Access block is inevitable and insoluble
AND / OR
– Can be sorted out by GP clinics, telephone lines or bigger/ better EDs
Major Myth-conceptions of ED overcrowding

4. Causation myths for Access block:
Caused by inappropriate / GP patients and poor ED practices
In response to the state of our public hospitals
AIHW report showing a 30% worsening in ED
patients time to be seen in WA
• “the pressure on emergency departments is
caused by patients seeking help who did not
need to be treated at hospital and should
have seen a GP instead.”
Acting Director-General Health WA 1/7/2008

5. GP patients – the evidence
• Tertiary EDs <15% GP “inappropriate”
• Use 3% or < of resources
• Easy - quick to treat
• 95% of stay in WR
• Admissions < 1% (v 5% triage category 5)
• Commonest attendance reason = GP referral
• Think (know) they should be there!
» Emerg Med Australas. 2005 Feb ;17 (1):11-5 15675899 Ambulance
diversion is not associated with low acuity patients attending Perth
metropolitan emergency departments. Peter Sprivulis
» Australian Health Rev 2004;28(3):285:291 After-hours general practice
clinics are unlikely to reduce low acuity patient attendances to metropolitan
Perth emergency departments. Nagree Y, Ercleve TN and Sprivulis P.C

6. 0
100
200
300
400
500
600
Minutes
ED LOS Awaiting
bed
Assessment
time
ED times for WA tertiary hospitals- proportion for
assessment
1999
2005
ED “play” with patients: the Data

7. Sensory perception- why people see this as
an ED problem?

8. Myth:
System Capacity loss doesn’t cause ED
overcrowding or poor outcomes

9. The Effect of Hospital Occupancy / Admissions in ED on:
ED LOS, Overcrowding and Pt Disposition/ Diversion
Research conclusions:
Hospital occupancy (admitted pts.) strongly associated w ED LOS
– Alan J. Forster MD, MSc , I Stiell et al; Academic Emerg Med Vol
10;2, p127 - 133 June-08
Admitted patients in ED are important determinant of ambulance diversion.
Reducing volumes of walk-in patients is unlikely to < the use of diversion.
– Michael J. Schull MD Ann Emerg Med. 2003;41:467-476.
ED overcrowding (r = 0.96; 95% confidence interval (CI) 0.91 to 0.98),
Ambulance diversion (r = 0.75; 95% CI 0.49 to 0.88), and
ED waiting times for care (r = 0.83; 95% CI 0.65 to 0.93) were
Strongly correlated with high ED occupancy by access blocked pts
• Fatovich D et al Emerg Med J 2005; 22:351-354
Capacity loss isn’t the cause of overcrowding?
The Evidence

10. Beds per 1000 of popn > 65 Australia

11. The data:
BEDS v Access BLOCK 1999 to 2006 WA
WA’s public beds have reduced 18% % of admitted patients Access Blocked
Australian public beds have reduced 10%
3.1
2.9
2.5
2.6
2
2.2
2.4
2.6
2.8
3
3.2
WA Australia
1999
2005
Beds per 1000 population
The state of our public hospitals, June 2006 report
0
10
20
30
40
50
60
FH RPH SCGH
2000
2001
2002
2003
2004
2005
2006
2007
DoH WA data

12. Access block in a department experiencing
major improvements in efficiency

13. Reducing LOS almost all countries

14. Bed no’s and occupancy -OECD

15. The Truth
• GP / “inappropriate” patients don’t
• Cause Access Block
• Use ED resource OR hospital capacity
• EDs don’t “stay and play” with patients
• Lack of Hospital and System capacity causes ED Overcrowding

16. Myth: Overcrowding- no consequences !

17. Myth: Overcrowding has minimal effect on patient care.
A deliberate mythology?
Standard DoH/ Health ministry responses minimising clinical
compromise from overcrowded EDs/ hospitals
“Western Australia now has some of the safest emergency departments in
the country, contrary to the findings of a 2003 report published in the
Medical Journal of Australia today. He said the report into overcrowding
in EDs was based on three-year-old information and many of the issues
raised were already being addressed”. 3/3/06
• Director Health Policy and Clinical Reform DoH WA in response to release of
Sprivulis et al mJA 2006 study showing OR of death of 1.3 in overcrowded WA
hospitals
“All public hospitals have procedures in place to ensure that patients who
present at emergency departments are promptly triaged and monitored,
and patients requiring urgent medical treatment are seen immediately,”
he said. 6/08
• A/DGH WA in response to concerns that an extra 2-300 patients a year were
probably dying due to chronic overcrowding in ED and hospitals
Access block from
2000-06
(worse again 2007)

18. Published adverse events from ED overcrowding
Deaths: 60-100 extra per 1 M population p.a.
Patients with time critical illness
e.g. Heart attack, trauma, stroke, pneumonia etc
• Delays to hospital ↑
• Delayed diagnosis and tx
• Complications, recurrence, deaths ↑
Pain relief ↓ amount ,↑ time
Starvation / dehydration
Errors ↑
LOS and Costs ↑
Complications ↑
(e.g. pressure sores/ DVT/ poor healing,,wrong tx)
Did not Waits ↑
Staff stress , burnout, turnover
Complaints/ legal issues/ press↑

19. The true effects of overcrowding
Delayed discharge
costing operations-
Qld Courier Mail
RIP
1200-3000pa
Nurses resign, 8 beds closed- WA News
'Demoralised' doctors
leaving NSW hospitals-
ABC

20. Reduced capacity in health systems –
not bad for patients?

21. Managing hospital overcrowding- myths
Best place for patients without a bed is ED

22. Q- who needs most expert, specialised care?
Acutely unwell, possibly deteriorating and undiagnosed
– OR
Patients who are stable, diagnosed and close to discharge
The 2000 year old
triage system
Myth- managing Access Block

23. Managing hospital overcrowding- myths
Best place for patients without a bed is ED
Differences in: ED Wards
(across hospital)
Beds/ space (% of hosp) 1-6% 50-90%
Space per patient 2 -4m2
3-8 m2
Additional spaces Minimal Spare rooms/ wait areas
Patient acuity Generally unwell –critical Stable- occas unstable
Standard bed Trolley- hard (bed sores >) Bed -soft (< bed sore)
Environment Noisy, light, no privacy, poor
access, frightening, irregular
food
Darkened, quiet, good access,
less frightening, regular meals
20 extra patients:
Effects on function
Functional capacity ↓40-80%
120-200% occupancy
Double/ triple rooms-corridor
functional capacity ↓ 2-5%
Run at 100-105% occupancy
Extra space 1 room- occas
corridor
Work practice alters? Yes- dramatic, change
function and nursing ratios ++
Minimal- moderate (worse if
patients on wrong units)
Staff morale Severe +++ Mild-moderate

24. The Truth
• Canadian Association of Emergency Physicians
Position Statement :
– “Emergency departments are loud, brightly lit environments
where patients lie on hard stretchers with limited privacy or
dignity, poor access to bathroom facilities, and little or no
opportunity for sleep. These are not reasonable, safe or
humane conditions for sick people. Patients requiring
hospital admission should not be held in emergency
departments, hallways or waiting rooms for more than 6
hours.”

25. What ED boarding really says

26. Solution myths

27. Myth
• ED overcrowding in Western health
systems is Inevitable AND Insoluble

28. The truth- avoidable / fixable
Key features of interventions that can
work are:
Capacity ↑
Activity ↓
and
System buy in
Overcrowding is a feature of
overzealous application of the
“efficiency” mantra that rations using
bed/ capacity cuts.

29. The Evidence
Examples:
Before 1999 Access Block was minimal in WA/ Qld/ ACT
UK A+E turned around with 4 hr targets- >90% achievement
When capacity ↑ activity ↓ e.g. holiday periods / strikes then
Access Block ↓ :
» Reduced access block causes shorter emergency department waiting times: An
historical control observational study – Dunn et al
» Effect of a holiday service reduction period on a hospital's emergency department
access block. Thomas J
Moving patients at 6 hrs to wards (overcensus):
ED function ↑ +++ / hospital LOS reduced by 1 day!
» Innes G et al Acad Emerg Med 2007 14(5) S1-8 Abs 206

30. SCGH :doubled ED capacity-
attendances from 40000 to 50000/ admit rate 45-47%

31. Solution myths- data
Clinics, Call Centres and Colossal EDs
Call centres
7 studies 5 RCT
No ↓ : 1 ↑ ED attendances
– Bunn F et aL Br J Gen Pract. 2005
December 1; 55(521): 956–961.
GP Clinics/Casualty
Little evidence for need
No ↓ local EDs attendances
Not Cost Effective
– Family Practice Vol. 20, No. 3,
311-317
– http://www.medeserv.com.au/acem
/open/documents/after_hoursgp.pd
f
Bigger-better ED*
Tennessee / WA
100% increase ED size
– Han JH Acad Emerg Med. 2007
Apr;14(4):338-43.
Outcomes
LOS in ED↑
Access block↑
Time to be seen↑

32. The Truth
ED overcrowding is not reduced by:
Co-located / alternative GP emergency services
Call centres- phone triage
Bigger / more efficient EDs
The reason is obvious:
They treat myths OR symptoms but not the Disease

33. Conclusions:
Myths are very bad for patients, staff and systems health
Access block causation:
Not “inappropriate” GP patients or ED practices
BUT a Systemic lack of capacity
Access block and overloaded EDs are associated with:
Severe avoidable adverse events and Deaths (> 1200 a year)
EDs are grossly inappropriate environments to “store” patients

34. Conclusions 2
ED Access Block is neither Inevitable nor Insoluble
It is a self induced disease of “efficiency” driven systems
GP clinics, call centers or bigger, better EDs can’t stop ED
overcrowding because they have little effect on the true cause
Things that we know do work (for a while):
Increased capacity – obs wards, strikes, stop surgery
Moving the patients to wards (share the problem)
Reduced in flows of sick patients ( ? Holland )

35. Acknowledgements
ED staff
AMA federal
AMA WA
Despair.com (demotivational posters)
DoH and MfH everywhere for making it
happen!

36. Hospitals Expand Emergency Rooms as
Patient Volumes Rise
By Birritteri, Athony
Publication: New Jersey Business