Will diversion of less urgent patients reduce emergency department access block
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Grant Innes^, Raul Martinez + , Michael Johnson + , Eric Grafstein* + ^Alberta Health Services (Calgary), +Vancouver Coastal Health; *Providence Health Care and St. Paul's Hospital. Will Diversion of Less Urgent Patients Reduce Emergency Department Access Block?. Disclosure.

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Will diversion of less urgent patients reduce emergency department access block l.jpg

Grant Innes^,

Raul Martinez+,

Michael Johnson+,

Eric Grafstein*+^Alberta Health Services (Calgary), +Vancouver Coastal Health; *Providence Health Care and St. Paul's Hospital

Will Diversion of Less Urgent Patients Reduce Emergency Department Access Block?


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Disclosure

  • I do not have an affiliation (financial or otherwise) with any commercial organization that may have a direct or indirect connection to the content of my presentation.


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Background

  • Emergency department (ED) overcrowding, better termed access block, is a situation where patients cannot access emergency care because all ED stretchers are occupied.

  • Many health experts believe that diversion of less urgent pts to other care locations (e.g. urgicentres) is an important part of the solution to access block.

  • Our objective was to estimate the impact of less urgent patient diversion on ED access block in an urban Canadian hospital, and compare that against other initiatives.


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Methods

  • We captured arrival and departure times, triage acuity levels and disposition for all pts seen over a one-year period at an urban tertiary ED.

  • Based on a 2-week observation of actual pt placements, we found that all admitted pts and 60% of non-admitted pts required a stretcher:

    • all CTAS1-2,

    • 79% of CTAS 3-4

    • 0% CTAS 5.


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Methods

  • Using a simulation model queuing system, we conducted a scenario analysis to determine how many stretchers were required to assure a 90% access rate (stretcher available for patients who need one 90% of the time).

  • We then modeled the impact of diverting 10% or 50% of CTAS level 4-5 patients and of reducing ED boarding times for admitted patients to 10 or 6 hrs.


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Results

  • During the study period, 62,100 patients were treated, including 30,040 CTAS 1-3 patients, and 32,060 CTAS 4-5 patients.

  • The model predicted that, at baseline, with an average admitted patient boarding time (LOS) of 15.5 hours, 50 ED stretchers would be required to achieve a 90% access rate.


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Baseline State

Access Rate vs. Stretcher Capacity

ADM LOS=15.5 hr

50 str for 90% access


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Access Rate vs. Stretcher Capacity

10% less urgent pts removed

Access Rate vs. Stretcher Capacity

ADM LOS=15.5 hr

50 str for 90% access


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Access Rate vs. Stretcher Capacity

50% of less urgent patients removed

Access Rate vs. Stretcher Capacity

With no reduction in ADM pt LOS, access curve does not shift

ADM LOS=15.5 hr

47 str for 90% access


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Access Rate vs. Stretcher Capacity

Baseline State

Access Rate vs. Stretcher Capacity

ADM LOS=15.5 hr

50 str for 90% access


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Access Rate vs. Stretcher Capacity

ADM Patient LOS reduced to 10 hr

Access Rate vs. Stretcher Capacity

ADM LOS=10 hours

38 str for 90% access


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Access Rate vs. Stretcher Capacity

ADM Patient LOS reduced to 6 hr

Access Rate vs. Stretcher Capacity

With red’n in ADM patient LOS, access curve does shift

ADM LOS=6 hours

33 str for 90% access


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Access Rate vs. Stretcher Capacity

ADM Patient LOS reduced to 6 hr

Access Rate vs. Stretcher Capacity

ADM pt LOS= 6 hrs, AND 50% less urgent patients removed

ADM LOS=6 hours

30 str for 90% access


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Results: Number of Stretchers required to achieve 90% access target


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Discussion

  • removing 10% of CTAS 4-5 visits had no impact on ED stretcher requirement,

  • removing 50% of less urgent patients reduced ED stretcher requirement by 6%.

  • reducing admitted pt boarding time to 10 hrs reduced stretcher requirement by 24%.

  • reducing admitted patient boarding time to 6 hours reduced stretcher requirement by 32%.

  • CTAS 4-5 patients less often need stretchers and occupy stretchers for less time, they have little impact on access for urgent and emergent patients


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Limitations

  • Model outputs are highly dependent on input assumptions. These may vary in different settings

  • % of patients requiring stretcher varies by site

    • Local practice (e.g. SJH Model)

    • Specific problems (e.g. CTAS 4 pts for sed’n/I+D)

  • Cannot model the complexity of real ED operations and ED contingency responses

  • Didn’t consider how long pt needs stretcher, and whether pts removed from stretchers

  • Does not consider new ED processes (RAZ)


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Conclusion

Simulation modeling using real patient arrival and departure data suggests that diverting less urgent patients to non-ED settings will have minimal impact on patient access to ED care, while reducing ED LOS (boarding times) for admitted patients will have a large impact


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