Time: the challenge sabotaging Emergency Departments

Acute Care

Time is the common variable linking the biggest challenges shaping today’s emergency departments and hospitals. Read the blog post to understand why.

Matilde Ferreira

February 1, 2023 · 7 min read

Millions of patients visit hospital emergency departments (EDs) each year for a variety of injuries and ailments. These patients must receive the appropriate care – timely – and the right preparation for their return home.

Healthcare professionals working in EDs have to be ready for anything, anytime. Every patient presents with varying degrees of health complications, and there are multiple interruptions, while the fast-paced environment keeps doctors and nurses on their toes. The growing need for on-demand care is pressing hospitals and burning out staff, while ED overcrowding adversely affects patients’ health, accessibility, and quality of healthcare.

“A complete state of crisis”: high affluence and excessive waiting times are sabotaging ER

“A complete state of crisis”, "intolerable and unsustainable"¹, “the perfect storm for collapse”², or even a “collapsed”² system. These are the words chosen by healthcare professionals working in EDs to describe the current situation:

By the end of 2022, Montreal (Canada) EDs hovered at about 150% capacity and some surpassed 200%.³
United Kingdom reported an 18% increase in Accident & Emergency (A&E) visits over the last six weeks of 2022 compared with the previous year.¹
Within the same period, each hospital in Lisbon (Portugal) recorded around 800 visits daily.⁴
In Spain, there are found reports of hospitals starting a new day with up to 110 patients waiting to be admitted to a ward.²

EDs are facing an ongoing pattern of rising demand, with a 2-3% annual increment tendency described in the literature.⁵ In Europe, 70-80% of hospital admissions are generated in the emergency room,⁵ and waiting has become a defining characteristic of the healthcare experience.

Today, a variety of problems converge to make ERs a pain point for healthcare professionals and managers. The root causes range from inappropriate visits also due to the lack of adequate support for primary care, and an offer-demand mismatch caused by the labor shortage crisis.

1. Non-urgent, inappropriate, and unnecessary visits

While there continues to be controversy surrounding the definitions of “non-urgent,” “inappropriate,” or “unnecessary” visits, the reality is that many people use EDs as their go-to place for healthcare, leading to unnecessary testing and treatment, wasting resources away, and increasing healthcare costs. Specifically, in developed countries 20% to 30% of ED visits are not emergent and thus, inappropriate.^6,7

Besides the entropies it poses to efficiency, increasing waiting times, and dispersing healthcare professionals’ focus, inadequate use of EDs has a significant impact on health costs. Data from the USA shows that approximately $4.4 billion could be saved annually⁸ by managing those patients in alternative sites.

However, the insufficient response from primary care to acute care is a flawed proxy for the challenge of lack of access that it was expected to reflect. A study from the Agency for Healthcare Research and Quality (AHRQ) found that having a primary care provider is not sufficient to deter frequent ED use by high-risk patients:

“Based on interviews with the enrolled patients and analysis of their responses to open-ended questions about barriers to care, other explanations for ED use primarily related to greater convenience and accessibility of ED care (e.g. limited office hours of primary care providers).” ⁹

That is to say, the problem of ED utilization is probably less the result of inappropriate patient decision-making, and more the result of healthcare’s inability to adapt to the needs and preferences of patients.¹⁰

Even admitting that not all the causes can be addressed from or by the ED, and call for care coordination approaches, there is room for improvement in non-emergent patients’ triage, fast track to exams and follow-up after discharge, leading to a more efficient use of patients and professionals’ time that we’ll be exploring on next blog posts.

2. Patients who leave the emergency department without being seen or during treatment

Patients presenting to a hospital’s ED who are triaged but leave without being seen (LWBS) by a physician or during treatment (LDT) are a major concern for healthcare providers.

The LWBS population, ranging from 1% to 10% of all triaged patients across EDs,¹¹ has been suggested to represent a shortfall in healthcare access and patient safety as these patients do not receive the care they sought when originally needed, consequently experiencing avoidable outcomes, and having a higher risk of re-presenting to an ED within 48 hours,¹² compared to those who complete the treatment.

While some studies report that patients who leave are probably not sick enough to be there and are recurrent visitors,¹³ others refute this claim and found those patients being hospitalized within 24 hours.¹⁴ However, there is a common point: every study looking at this issue blames overcrowding and excessive wait time as primary reasons for leaving.

Hospitals’ “bottom lines” are affected directly in the way of lost revenues from opportunities missed in delivering care and indirectly in the form of reimbursement penalties from a decrease in satisfaction scores.

While recruitment and retention efforts are needed, they seem insufficient to handle such a complex challenge: providers should redesign patients’ flow and find strategies to optimize appointments in order to create the time needed for those patients.

3. Discharge failures leading to readmissions

Poor hospital discharge practice leads to unnecessary patient suffering, wasted resources, and readmissions. In the United Kingdom, there are found more than a million emergency readmissions within 30 days of discharge, annually, costing more than £2.4 billion.¹⁵

The available literature defines a high-quality ED discharge as one that contains three main characteristics:

Informs and educates patients on their diagnosis, prognosis, treatment plan, and expected course of illness.
Supports patients in receiving post-ED discharge care.
Coordinates ED care within the context of the health care system (other health care providers, social services, etc.).

The fast-paced nature of the ED exacerbates the challenge of ensuring comprehension of discharge instructions - the risk factor most reported among patients screened by the AHRQ.⁹

Besides discharge instructions and education, as while as prescription assistance, possible interventions include structured post-visit follow-up able to keep patients on track and anticipate unexpected episodes. Read our next blog post to better understand how UpHill structures post-discharge follow-up and improves care coordination.

4. Managing stress, workload, and liability

The emergency room is, by its very nature, a high-pressure, busy, and constantly changing setting to work in, which for most people can be quite stressful. With an often-large number of people waiting to be seen, and different roles of interlinked staff members, whose work is mutually influenced, it can be an overwhelming amount of people to coordinate in one area.

Additionally, seen as the front door of healthcare services, there are periods in which the ED becomes somewhat chaotic, and this can create a difficult workplace for some staff.

Working in hospital emergency departments is, indeed, related to increased stress levels,¹⁷ mainly due to:

Decision-making: healthcare professionals need to make quick decisions under high pressure, with accuracy holding life-changing weight.
Nonspecific or vague symptoms: it is an enormous challenge requiring skill and experience to sort out which of these individuals have potentially life-threatening conditions and which may be safely discharged home.
Patient anxiety: healthcare professionals need to manage agitated patients.
Resource scarcity: working with no inpatient beds available has been an increasing concern among EM residents over the past ten years.¹⁸
Workload: working while many other patients waiting to be seen in the waiting room is mentioned as an additional stress factor.

Even so, the main drivers of physician burnout aren’t stress and exhaustion, they are mundane tasks like charting, paperwork, and healthcare bureaucracy. In this context, providers are called on to reduce workload, while supporting difficult and pressed care decisions.

Takeaways:

EDs are facing an ongoing pattern of rising demand, with the number of admissions growing year by year.
Lack of time, rush/pressure, and waiting times are widely used words to describe EDs environment.
Strategies to improve triage and patient stratification, as well as resolutive interactions and optimize appointments enhancement are needed to improve EDs performance.
Optimize EDs efficiency request also processes’ redesign, striving for more efficient use of patients’ and professionals’ time.
Care should not end with patient discharge and follow-up after discharge strategies are crucial to reduce preventable visits and readmissions, increasing waiting times and healthcare costs.
Hospitals are losing workforce, that feel burned-out of constantly working under pressure, and must find the tools needed to strengthen HCPs’ confidence during decision making and relieve them from low value tasks.
References
1. Adams, C. (2023) Pressure on the NHS is unsustainable, Medics Warn, BBC News. BBC. Available at: https://www.bbc.com/news/health-64142614 (Accessed: January 30, 2023).
2. McMurtry, A. (2023) In Spain, emergency rooms overflow, patients wait days to be admitted, Anadolu Ajansı. Available at: https://www.aa.com.tr/en/europe/in-spain-emergency-rooms-overflow-patients-wait-days-to-be-admitted/2785382 (Accessed: January 30, 2023).
3. Shingler , B. (2022) Canada's ERS are under intense pressure - and winter is Coming | CBC news, CBCnews. CBC/Radio Canada. Available at: https://www.cbc.ca/news/canada/canada-ontario-quebec-bc-alberta-emergency-rooms-1.6616811 (Accessed: January 30, 2023).
4. Hospitais da Região de Lisboa com elevada Procura nas Urgências (2022) DN. Diário de Notícias. Available at: https://www.dn.pt/sociedade/hospitais-da-regiao-de-lisboa-com-elevada-procura-nas-urgencias-15335474.html(Accessed: January 30, 2023).
5. European Emergency Medicine in Numbers (2020). EUSEM - European Society for Emergency Medicine. Available at: https://eusem.org/images/European_EM_in_numbers.pdf (Accessed: January 30, 2023).
6. OECD (2017), Tackling Wasteful Spending on Health, OECD Publishing, Paris, https://doi.org/10.1787/9789264266414-en.
7. Uscher-Pines, L., Pines, J., Kellermann, A., Gillen, E., & Mehrotra, A. (2013). Emergency department visits for nonurgent conditions: systematic literature review. The American journal of managed care, 19(1), 47–59.
8. Weinick, R. M., Burns, R. M., & Mehrotra, A. (2010). Many emergency department visits could be managed at urgent care centers and retail clinics. Health affairs (Project Hope), 29(9), 1630–1636. https://doi.org/10.1377/hlthaff.2009.0748
9. Pham, J.C., Bayram, J.D. and Moss, D.K. (no date) Characteristics of frequent users of three hospital emergency departments, AHRQ. Available at: https://www.ahrq.gov/patient-safety/settings/emergency-dept/frequent-use.html#intro (Accessed: January 30, 2023).
10. Chaiyachati K, Kangovi S. Inappropriate ED visits: patient responsibility or an attribution bias? BMJ Quality & Safety 2020;29:441-442.
11. Li, D. R., Brennan, J. J., Kreshak, A. A., Castillo, E. M., & Vilke, G. M. (2019). Patients Who Leave the Emergency Department Without Being Seen and Their Follow-Up Behavior: A Retrospective Descriptive Analysis. The Journal of emergency medicine, 57(1), 106–113. https://doi.org/10.1016/j.jemermed.2019.03.051
12. Tropea, J., Sundararajan, V., Gorelik, A., Kennedy, M., Cameron, P., & Brand, C. A. (2012). Patients who leave without being seen in emergency departments: an analysis of predictive factors and outcomes. Academic emergency medicine: official journal of the Society for Academic Emergency Medicine, 19(4), 439–447. https://doi.org/10.1111/j.1553-2712.2012.01327.x
13. Li, D. R., Brennan, J. J., Kreshak, A. A., Castillo, E. M., & Vilke, G. M. (2019). Patients Who Leave the Emergency Department Without Being Seen and Their Follow-Up Behavior: A Retrospective Descriptive Analysis. The Journal of emergency medicine, 57(1), 106–113. https://doi.org/10.1016/j.jemermed.2019.03.051
14. Roberts, James R. MD. Patients Who Leave the ED Without Being Seen. Emergency Medicine News 27(11):p 18-22, November 2005.
15. Poor discharge practice leading to 'unnecessary patient suffering' (2015) NICE. Available at: https://www.nice.org.uk/news/article/poor-discharge-practice-leading-to-unnecessary-patient-suffering(Accessed: January 30, 2023).
16. Boonyasai, R.T. et al. (2014) Improving the emergency department discharge process: Environmental ..., Agency for Healthcare Research and Quality. Available at: https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/edenvironmentalscan/edenvironmentalscan.pdf (Accessed: January 30, 2023).
17. García-Tudela, Á., Simonelli-Muñoz, A. J., Rivera-Caravaca, J. M., Fortea, M. I., Simón-Sánchez, L., González-Moro, M. T. R., González-Moro, J. M. R., Jiménez-Rodríguez, D., & Gallego-Gómez, J. I. (2022). Stress in Emergency Healthcare Professionals: The Stress Factors and Manifestations Scale. International journal of environmental research and public health, 19(7), 4342. https://doi.org/10.3390/ijerph19074342
18. Perina DG, Marco CA, Smith-Coggins R, Kowalenko T, 6 ©JWellness 2021 Vol 3, (2) Johnston MM, Harvey A. Well-Being among Emergency Medicine Resident Physicians: Results from the ABEM Longitudinal Study of Emergency Medicine Residents. J Emerg Med. 2018 Jul;55(1):101–109.e2.

Matilde Ferreira

Content Strategy & Communication Manager

Graduated in Communication Sciences, early on fell in love with storytelling. Started off as a journalist and then pivoted to the public relations world, she was always driven to craft relevant stories and bring them to the stage.