Patient Flow at Emergency Department – The Safety Net of Health Care System

personnel in ED although the number of nurses deployed needs to be increased. Patients admitted at ED reception are shifted to medical and surgical observation units or directly to the concerned speciality. The average length of stay (ALOS) of patients from different specialities in medical observation unit is shown in Table 1. The average length of stay of different specialities in medical observation unit is 2 where as average vacant beds is 1.87% (0.6 beds). The ALOS of different specialities in surgical observation unit along with their occupancy is shown in Table 2. The ALOS of different specialities in surgical observation unit is 2.05 while as average number of vacant beds daily is 16.07% (4.5 beds). On an average 1.33 patients/day abscond from ED reception. 95% of these patients abscond along with patient record because of overcrowding at ED reception, rest of the patients leave because of family problems, go to a private practitioner etc. On an average 9 patients were operated everyday in emergency OT during study period. Patients from observation units are shifted to concerned specialities or are discharged. Some patients need to be shifted to high dependency area. Patients in specialities are admitted either from ED or from out patient department. Table 3 shows the number of patients admitted from ED and Outpatient Department along with ALOS and number of vacant beds in different specialities. Table 4 shows the specialities whose OPD admission is routinely blocked. 5 tant as external factors in determining ED overcrowding. Three general themes exist among the causes of ED crowding: Input, Throughput and Output factors. These themes correspond to a conceptual frame work for studying ED crowding. Input factors reflect sources and aspects of patient inflow. Throughput factors reflect bottlenecks within the ED. Output factors reflect bottlenecks in other parts of the 6 health care system that might affect the ED. Effort was made at Sher-i-Kashmir Institute of Medical Sciences (SKIMS) to study patient flow in ED and identify bottlenecks if any.

personnel in ED although the number of nurses deployed needs to be increased.Patients admitted at ED reception are shifted to medical and surgical observation units or directly to the concerned speciality.The average length of stay (ALOS) of patients from different specialities in medical observation unit is shown in Table 1.
The average length of stay of different specialities in medical observation unit is 2 where as average vacant beds is 1.87% (0.6 beds).
The ALOS of different specialities in surgical observation unit along with their occupancy is shown in Table 2.
The ALOS of different specialities in surgical observation unit is 2.05 while as average number of vacant beds daily is 16.07%(4.5 beds).
On an average 1.33 patients/day abscond from ED reception.95% of these patients abscond along with patient record because of overcrowding at ED reception, rest of the patients leave because of family problems, go to a private practitioner etc.On an average 9 patients were operated everyday in emergency OT during study period.Patients from observation units are shifted to concerned specialities or are discharged.Some patients need to be shifted to high dependency area.
Patients in specialities are admitted either from ED or from out patient department.Table 3 shows the number of patients admitted from ED and Outpatient Department along with ALOS and number of vacant beds in different specialities.Table 4 shows the specialities whose OPD admission is routinely blocked.Effort was made at Sher-i-Kashmir Institute of Medical Sciences (SKIMS) to study patient flow in ED and identify bottlenecks if any.

Methods
This prospective study was carried over a period of two weeks at SKIMS in the month of December 2011.The researchers would record at 10am everyday the number of registrations made at ED during previous twenty four hours.Number of inpatient admissions made through ED during same period would also be recorded.The number of patients being observed at main reception of ED would also be recorded at 10am everyday.The patients who were at main reception for more than two days would be noted and reasons for their overstay recorded.The patient details for two observation wards one each for Medicine and Surgery were recorded everyday at 10am in terms of diagnosis, speciality under which admitted and length of stay in ED.The patients who need to stay as inpatient are as a protocol to be shifted to concerned speciality within forty eight hours from ED.The details of patients admitted in different specialities in terms of diagnosis, length of stay and reasons for overstay if any were also noted.Admission and discharge registers in these wards were studied to note down the route of admission i.e., via ED or Out patient Department.To facilitate shifting of patients from ED administration as a policy blocks routine (out Patient) admission of specialities who have long stay patients in ED.The specialities whose out patient admission was blocked were recorded for the study period.

Results
On an average 175 registrations are made at SKIMS Emergency Department during twenty four hours out of which 39 on an average are admitted with an admission rate of 22.3%.Most of these patients do not earn treatment at a tertiary care facility.On an average 41 patients are under treatment at a given moment at reception of ED as full stay patients.In addition to this 12 patients on an average are being observed at any moment as card patient at the reception.On an average there are six patients at ED reception who have length greater than two days.60% of these patients do not have a bed with oxygen facility available in medical observation unit while as 20% do not have availability of bed in surgical observation unit.Occasionally a stable patient has to be at reception of ED waiting for surgery due to busy emergency OT.There is adequate deployment of medical

Discussion
175 patients on an average attend SKIMS ED within twenty four hours out of which 22.3% of patients are admitted .Seeing the profile of patients admitted most of the patients should have been treated at primary care level or secondary care level only.This strongly emphasizes the need to study ED crowding in context of multicenter community 7 networks rather than single institution.Issue of ambulance diversion (referring patients to other hospitals) may be 7 considered a cause, effect or solution of ED crowding.SKIMS being a tertiary care centre, it is a important cause of overcrowding.Non urgent visits so called frequent flyer patient have also been seen as a cause of overcrowding.Three studies have identified low acuity ED patients seeking non urgent care in ED and the reason for this being insufficient or 8-10 untimely access to primary care.Frequent flyers are not a cause of overcrowding at SKIMS.One study reported frequent visitors defined by four or more annual visits 11 contributing to 14% of total ED visits.Similar report found that 500 most frequent users of one ED accounted for 8% of total visits and 29% of these visits might have been appropri-12 ate for Primary care.
As is clear from results 50 patients on an average are being treated at ED reception, the space which is meant for maximum of 16 patients.The hospital crowding is primarily regarded as a consequence of inadequate medical resources.The situation can be potentially improved by optimizing the utilization of medical resources e.g., bed, equipment and personnel.Recent research has shown that highly stochastic process of incoming patients causes the violation of resources 13 which lead to crowding.However, simply expanding medical care capacity may do little to relieve the emergency department crisis though one hospital increased both space and staffing through an ED reorganization which resulted in 14 the improvement of several crowding outcomes.Increasing space at SKIMS ED reception which holds more patients than its capacity may give some relief but it will be short lasting if proper referral system is not developed in the state of Jammu & Kashmir.Inadequate staffing has been identified The division of ED into Medical and surgical observation units is not justified as it leads to compartmentalisation and creation of dead space.ED over a period of time has evolved as a separate speciality in itself and emergency physicians are trained to handle all sorts of emergencies.In medical observation unit the speciality of General Medicine has an ALOS of 3.07 with an occupancy of 67%, while as in surgical observation unit Neurosurgery has ALOS and percentage occupancy on higher side.The shifting of admitted patients from ED depends on through put factors in the parent speciality.Specialities of Gastroenterology, General Medicine and Neurology have more patients admitted through ED than patients admitted through OPD.Since 2004 EDs in UK have been required to ensure that at least 98% of patients are either discharged or admitted to hospital within four hours of arrival.Forty four percent of 19 acute trusts are still failing to meet the 98% target.Analysis of data from Nationwide Inpatient Sample (NIS), the largest database in U.S in patient care showed number of hospital admissions increased by 15% in 2006 and admissions from ED increased by 50.4% in same period.The Proportion of all inpatient stays involving admission from ED increased from 33.5 to 43.8% (p<0.001).It was observed that patients who historically would be admitted through OPD also would find In conclusion, the increasing use of EDs for inpatient admissions has important implications for the redesign of the healthcare delivery system.The review of literature shows that ED crowding is a local manifestation of a systemic disease.The focus has to be multipronged i.e., on Input, Throughput and Output Factors.While as control on input demands wider participation at multicentric community levels, hospitals can focus on the other two class of factors.There has to be clear focus on efficient use of inpatient resources.More research is required to develop new models of acute care delivery to protect the fragile safety net of health care system.

5 tant
as external factors in determining ED overcrowding.Three general themes exist among the causes of ED crowding: Input, Throughput and Output factors.These themes correspond to a conceptual frame work for studying ED crowding.Input factors reflect sources and aspects of patient inflow.Throughput factors reflect bottlenecks within the ED.Output factors reflect bottlenecks in other parts of the 6 health care system that might affect the ED.

7 , 15 by
some studies to be an important cause of overcrowding.Main reason for patient developement at SKIMS ED is overcrowding.Many articles have characterized patient elopement from ED. Patients have been seen more likely to leave without being seen when ED occupancy exceeded 16 100% of the total capacity.The rate of patients leaving one ED without being seen correlated well with a crowding 17 regression model.Studies have reported rate of patients leaving without being seen closely correlating with waiting 17,18 times.

TABLE 4 . Showing specialities whose OPD admission is blocked along with percentage of times it is done
Several explanations were given to this growing role.One frequently cited hypothesis is that reduced access to primary care leads to worsening of patients condition and that emergency physicians are more likely than primary care physicians to admit patients based on the assumption that they are trained to assume the worst and more likely to admit patients with uncertain diagnosis and 20 with whom they don't have an ongoing relationship.Alternately the trend could be driven by changes in the organization of medical services that favour the rapid diagnostic technologies and early treatment available in the ED.In addition primary care providers and out patient providers are difficult to be contacted by a patient for a sick visit because schedules are full and after hours service is unavailable.Yet since hospital practices have largely been reactive, it is unclear whether this trend reflects high value use of limited emergency care resources and whether it has resulted in more or less appropriate use of scarce inpatient 20beds.