Emergency department overcrowding:causes and solutions

Background:Emergency department(ED)overcrowding is among the biggest and most important problems experienced by ED staff.The number of ED visits is on the increase and remains an unresolved problem.Emergency department overcrowding has become an important problem for emergency care services worldwide.There is a relationship between overcrowding and patients’negative experi-ences of using ED and therefore reporting reduced patients’satisfaction.This study aimed to identify the causes of ED overcrowding,de-termine the reasons for people’s use of EDs,and develop solutions for reducing ED overcrowding.Methods:This study used quantitative methods using a descriptive approach.The participants were patients who visited the ED.A questionnaire was administered to 296 participants between December 2021 and February 2022.The study included 5 different hospitals in Turkey.The data were analyzed using descriptive statistics.Results:This study identified the most common presenting medical problems in the ED and why patients used the ED.Reasons for using the ED included patients perceiving their condition as really urgent(62.8%),the ED being open for 24 hours(36.1%),and receiving faster care in the ED(31.4%).This study also developed recommendations for alleviating ED overcrowding.Conclusion:This study identified causes of ED overcrowding and some solutions for alleviating the issue.Emergency department over-crowding should be perceived as an international problem,and initiatives for solutions should be implemented quickly.

A new medical safety factor for critical patients： emergency department overcrowding

Emergency department （ED） overcrowding is a worldwide problem which is common in daily practiceand after disasters.During dally practice, it is more so in large hospitals. ED overcrowding may cause a series of adverse outcomes such as prolonged waiting time for treatment, an increase in ambulance diversion and a reduction in working efficiency.4 Therefore, it is urgently necessary to clearly define ED overcrowding and search for effective ways to solve the problem.

Concept Analysis: Emergency Department Crowding and Length of Stay before and after an Increase in Catchment Area

Several notable issues arise from overcrowding in an emergency department (ED) for both patients and staff. Longer wait times, higher ambulance diversion rates, longer stays, higher incidence of medical errors, higher rates of patient mortality, and greater harm to hospitals due to financial losses are some of these problems. Collaboration is crucial in the healthcare industry since it determines the team’s hourly performance in managing patient care. By using Walker and Avant’s (2011) concept analysis method, the author reviewed the literature to better understand ED crowding, to ensure that patients receive safe treatment in a timely manner, and to highlight best practices that can be identified through concept analysis and practice evaluations. In conducting this concept analysis, Walker and Avant’s framework was applied to examine the nature of the findings selected for the advancement of the concept. Everyone working in the ED, from those who determine policy to those on the front lines continually encounter new obstacles, but has little or no time to formulate fresh concepts or reconsider how ED treatment is provided. Overcrowding occurs when the number of patients requiring attention, awaiting transfer, or undergoing diagnosis and treatment exceeds the physical capacity of ED staff. If a clear plan is not in place to increase and improve services in proportion to a growing population, this situation will persist.

The Definition of Non-Urgent Visits to the Emergency Department and Validation of Criteria for Referrals

Background: The centers of disease control and prevention define a non-urgent Emergency Department (NU-ED) visit as a medical condition requiring treatment within more than 24 hours. These visits constitute one of the main reasons for emergency department (ED) overcrowding, which greatly affects healthcare workers’ wellbeing, health costs, patients’ satisfaction and treatment outcomes. Currently, there is no solid definition of non-urgent emergency visits, which is the first step towards dealing and potentially solving this issue. Having that, the aim of the current study is to define and validate the criteria for NU-ED visits in Israel. Methods: This qualitative study included twelve senior physicians and nurses working in Emergency Department and/or Health Maintenance Organizations (HMOs) across Israel. The study was performed using in-depth, semi-structured, open-ended interviews. Qualitative data analysis was performed by conventional content analysis. Results: The urgency of medical visits was defined based on these two questions: 1) Does the medical condition require an immediate treatment? 2) Is the emergency department the only place that can provide the required treatment at a certain timepoint? We found that non-urgent visits mostly occur during the nights and weekends, when medical treatments are not available in the HMOs. Visitors for non-urgent cases mostly complained about minor injuries or chronic conditions, fever, abdominal or chest pain. Most visits occurred based on referral from the family physician or the nurse from the call center. Participants reported a lack of awareness and knowledge about the roles of the EDs and the available options in the HMOs, which seem unable to provide patients with appropriate treatments. The usage of triage scales seems to ensure that patients are being treated based on the clinical urgency of their condition. Medical cases that score above 3 can be defined as non-urgent visits. Therefore, implementation of these scales in the community and their use in decision making of referrals to emergency department might greatly reduce non-urgent visits. Conclusions: Participants defined urgent ED visits as medical situations that need to be treated immediately, while there are no available treatment options in the HMOs. Participants identified many reasons behind NU referrals to the ED, mainly, low awareness about the role of ED, low availability of certain tests in the HMOs, and inability to provide adequate treatment in the community.

Correlation between crowdedness in emergency departments and anxiety in Chinese patients

BACKGROUND Emergency department(ED)overcrowding is a severe health care concern,while anxiety and depression rates among ED patients have been reported to be substantially higher compared to the general population.We hypothesized that anxiety due to over crowdedness may lead to adverse events in EDs.AIM To investigate correlations between crowdedness in EDs and anxiety of patients and nurses,and to identify factors affecting their anxiety.METHODS In this prospective observational study,a total 43 nurses and 389 emergency patients from two tier III hospitals located in Beijing were included from January 2016 to August 2017.Patients were grouped into inpatients when they were hospitalized after diagnoses,or into outpatients when they were discharged after treatments.The State Trait Anxiety Inventory(STAI Form Y)questionnaire was used to investigate patient and nurse anxieties,while crowdedness of EDs was evaluated with the National Emergency Department Over Crowding Score.RESULTS The present results revealed that state anxiety scores(49.50±6.00 vs 50.80±2.80,P=0.005)and trait anxiety scores(45.40±5.70 vs 46.80±2.70,P=0.002)between inpatients(n=173)and outpatients(n=216)were significantly different,while the state anxiety of nurses(44.70±5.80)was different from those of both patient groups.Generalized linear regression analysis demonstrated that multiple factors,including crowdedness in the ED,were associated with state and trait anxieties for both inpatients and outpatients.In addition,there was an interaction between state anxiety and trait anxieties.However,multivariable regression analysis showed that while overcrowding in the ED did not directly correlate with patients’and nurses’anxiety levels,the factors that did correlate with state and trait anxieties of inpatients were related to crowdedness.These factors included waiting time in the ED,the number of patients treated,and the number of nurses in the ED,whereas for nurses,only state and trait anxieties correlated significantly with each other.CONCLUSION Waiting time,the number of patients treated,and the number of nurses present in the ED correlate with patient anxiety in EDs,but crowdedness has no effect on nurse or patient anxiety.

The importance of household composition in epidemiological analyses of sleep: Evidence from the Understanding Society longitudinal panel survey

Aims: To establish the relationship between household composition and sleep, we: 1) used latent class analysis (LCA) to classify households;2) examined the reliability and stability of household composition classes over time;3) conducted multinomial logistic regression analyses to determine the relationship between household class and the self-reported sleep duration and quality of adults. Methods: Data were sourced from Waves 1 and 2 of the United Kingdom “Understanding Society” (USoc) longitudinal panel survey. LCA was used to classify household composition as a categorical latent construct using data on the number and ages of household occupants and the number of rooms used for sleeping. The Bayesian Information Criterion assessed model fit and identified the optimum number of latent classes. Multi-nomial logistic regression was used to investigate cross-sectional relationships between the household classes and self-reported sleep duration and quality amongst adults, after adjustment for confounders. Results: Household composition was best defined by 7 latent classes in data from Wave 1 of USoc. This finding was confirmed in Wave 2. Compared to the reference class (households with no children and no overcrowding), there was a higher risk of short sleep (≤5 hours) versus 7-8 hours sleep for latent household composition classes that included children (RR: 1.56;95% CI: 1.29-1.89) and for those with both children and overcrowding (RR: 1.57;95% CI: 1.31-1.88). Similarly the risk of “very bad” versus “fairly good” quality sleep was significantly higher in those household classes with overcrowding, particularly those with extended (RR: 1.75;95% CI: 1.34-2.29) and large (RR: 1.51;95% CI: 1.21-1.87) households. Conclusion: These analyses of a recent, nationally representative cohort from the UK, demonstrated that latent household composition classes are reliable over time;and that these latent household composition classes are important correlates of self-reported sleep amongst adult occupants. We showed that household composition is an important contextual variable to consider in most epidemiological studies of sleep.

Emergency department visits:Why adults choose the emergency room over a primary care physician visit during regular office hours?

BACKGROUND:It has been estimated that up to one third of all emergency department(ED)visits may be"inappropriate"or non-emergent.Factors that have been speculated to be associated with non-emergent use have been noted to include low socioeconomic status,lack of access to primary care,lack of insurance,convenience of"on demand care"and the patient's individual perception of their complaint urgency.The objective of this study is to identify the reasons contributing to self-perceived non-emergent adult emergency department visits during primary care physician office hours of operation.METHODS:This study was a single-center,descriptive study with questionnaire.The questionnaire was collected from patients meeting exclusion/inclusion criteria who were triaged into an acute or fast track part of the emergency department during regular business hours on Monday through Friday,8:00 am-5:00 pm during the months of July 2011 and August 2011.Questionnaire data were categorical and summarized using counts and percentages.Data collected included patient demographics,information about the patient's primary care provider,and information about the emergency department visit in question.All responses were compared among patients with visits considered to be non-emergent to those considered to be emergent by using individual chi-square tests.RESULTS:There were 262 patients available for the study.The patients were grouped according to their perception of the severity of their complaints.Roughly half of the patients placed themselves into the non-emergent category(n=129),whereas the other half of the patients categorized themselves into the emergent group(n=131).There were statistically significant differences in marital status and employment status between the two groups.It was found that 61.5%of the non-emergent patients were single,while 58.3%of the emergent patients were married.In the non-emergent group,59.7%were unemployed,but in the emergent group 60.3%were employed(P<0.05).However,no other factors were significantly different.CONCLUSIONS:Our study did not identify a statistically significant factor to the reasoning behind why patients choose the emergency department over a primary care physician during regular office hours.The only significant demographic indicating who was more likely to make this choice during the specified time frame was being single and employed with perceived non-emergent complaint.Patients without insurance and/or without a primary care physician were no more likely to visit the emergency department with a self-perceived non-emergent issue than patients with insurance and/or with an established primary care physician.

Analysis of Triage Application in Emergency Department

Objectives: In this study, we aimed to determine the current status of Green Zone (GZ) application in our Emergency Department (ED). We also sought workload and economic burden of GZ on both healthcare providers and health system. Methods: We analyzed the medical data of patients admitted to the GZ of our ED in a three-year period. Demographical characteristics, complaints on admission, number of revisits and economical cost of the patients were determined. Results: During 3-year period a total of ~900,000 patients were admitted to Hitit University Corum Education and Research Hospital ED. Of these patients, 87,089 patients were treated in GZ. Upper respiratory system disease was the leading complaint on admission. Mean length of stay in ED for these patients was found to be 22.2 minutes. When repeated visits were investigated, it was found that 3029 patients presented twice to the GZ. Conclusion: Certain measures to reduce number of non-emergent patients presenting to ED must be taken immediately. Or else, dissatisfaction of both healthcare providers and patients shall remain as a potential cause of unwanted events in over-crowded EDs in the future.

Discrimination of Structural Isomers of Aromatic Compounds with EI Mass Spectra and Their Ionization Efficiency Curves of Dehydrogenated Fragment Ions

The mechanism of ionization and fragmentation for terphenyl (diphenylbenzene) with three structural ring isomers (ortho-, meta- and para-), and stilbene (1,2-diphenylethylene) with two geometrical isomers (trans- and cis-) by EI mass spectrometry and ionization efficiency curves are investigation.

Genome-wide analysis of Nilaparvata lugens nymphal responses to high-density and low-quality rice hosts

The brown planthopper （BPH） Nilaparvata lugens is an economically impor- tant pest on rice plants. In this study, the higher population density and yellow-ripe stage of rice plants were used to construct adverse survival conditions （ASC） against BPH nymphs. Simultaneously, the low population density and tillering stage of rice plants were used to establish a suitable survival condition （SSC） as a control. Solexa/Illumina sequencing was used to identify genes of BPH nymphs responding to ASC. Significantly longer duration development of BPH nymphs and significantly lower brachypterous ratio of BPH adults were observed by ASC compared with SSC. A total of 2 544 differentially expressed genes （DEGs） were obtained and analyzed by BLASTx, Gene Ontology and KEGG Orthology. Gene ontology analysis revealed that the DEGs were mainly involved in categories of cell, cell part, cellular process, binding, catalytic, organelle and metabolic processes. 1138 DEGs having enzyme commission numbers were assigned to different metabolic pathways. The largest clusters were neurodegenerative diseases （137, 12.0%）, followed by carbohy- drate metabolism （113, 9.9%）, amino acid metabolism （94, 8.3%）, nucleotide metabolism （76, 6.7%）, energy metabolism （64, 5.6%）, translation （60, 5.3%）, lipid metabolism （58, 5.1%）, and folding, sorting and degradation （52, 4.6%）. Expressing profile of 11 DEGs during eight nymphal developmental stages of BPH were analyzed by quantitative real- time polymerase chain reaction. The 11 genes exhibited differential expression between ASC and SSC during at least one developmental stage. The DEGs identified in this study provide molecular proof of how BPH reconfigures its gene expression profile to adapt to overcrowding and low-quality hosts.

Evaluation of the risk factors associated with emergency department boarding:A retrospective cross-sectional study

Purpose Boarding is a common problem in the emergency department(ED)and is associated with poor health care and outcome.Imam Khomeini Hospital is the main healthcare center in Urmia,a metropolis in the northwest of Iran.Due to the overcrowding and high patient load,we aim to characterize the rate,cause and consequence of boarding in the ED of this center.Methods All medical records of patients who presented to the ED of Imam Khomeini Hospital from August 1,2017 to August 1,2018 were retrospectively analyzed.Patients with uncompleted records were excluded.Boarding was defined as the inability to transfer the admitted ED patients to a downstream ward in≥2 h after the admission order.Demographic data,boarding rate,mortality and triage levels(1–5)assessed by emergency severity index were collected and analyzed.The first present time of patients was classified into 4 ranges as 0:00–5:59,6:00–11:59,12:00–17:59 and 18:00–23:59.Descriptive,parametric and non-parametric statistical tests were performed and the risk of boarding was determined by Pearson Chi-square test.Results Demographic data analysis showed that 941(58.5%)male and 667(41.5%)female,altogether 1608 patients were included in this study.Five patients(0.3%)died.The distribution of patients with the triage levels 1–5 was respectively 79(4.9%),1150(71.5%),374(23.3%),4(0.2%)and 0(0%).Most patients were of level 2.Only 75(4.7%)patients required intensive care.The majority of patients(84.2%)were presented at weekdays.The maximum patient load was observed between 12:00–17:59.Of the 1608 patients,340(21.1%)experienced boarding within a mean admission time of 13.70 h.Among the 340-boarded patients,20.1%belonged to surgery,12.1%to orthopedics,10.9%to neurosurgery and 10.3%to neurology.The boarding rate was higher in females,patients requiring intensive care and those with low triage levels.Compared with the non-boarded,the boarded patients had a higher mean age.Conclusion The boarding rate is higher in the older and female patients.Moreover,boarding is dependent on the downstream ward sections:patients requiring surgical management experience the maximum boarding rate.

Exploring attendance at emergency departments for children with non-urgent conditions in Turkey: a qualitative study of parents and healthcare staff perspectives

Background:Overcrowding in Emergency Departments(EDs)is a significant global concern with negative consequences for patients,healthcare staff,and healthcare systems.The use of EDs by parents of children with non-urgent conditions is associated with overcrowding,higher healthcare costs,lower quality of care,and longer waiting times.Research in this area has largely been conducted in high-income countries,with a dearth of work originating in middle and low-income regions.The aim of this study was to explore the reasons for parents attending EDs with their child for non-urgent conditions in Turkey.Method:Semi-structuredinterviews wereconductedwith 13parents,15 EDstaff,and10GeneralPractitioners(GPs)in2 regions of Turkey between March and May 2017.Data were analyzed using the principles of grounded theory.Results:The findings were classified into 5 core categories:(1)parents’feelings,knowledge,and perceived inability to provide self-care;(2)perceived limitationsofhealthcare services,system,and staff;(3)parents’preferencesforhospital andED services;(4)adverse impact on ED services;and(5)perceived needs for care.Conclusion:This is the first study conducted in a middle-income country regarding parental reasons for using the ED for non-urgent conditions.Greater efforts must be made to reduce unnecessary visits to the ED to better meet service user needs and to increase the satisfaction of both parents and healthcare staff.The findings of this study may inform healthcare providers,policymakers,healthcare staff,and researchers to design interventions in order to mitigate overcrowding in the ED.