Managing
Overcrowded in
Emergency Service
WAHYUNI DIAN PURWATI
ED COMMITTEE – SILOAM HOSPITALS GROUP
IDEAL vs REAL
OVERCROWDING DEFINITION
• The need for emergency healthcare services exceeds
VARIOUS the available resources to provide emergency care to
patients within appropriate time frame
DEFINITION • Imbalance in service provision
TRUE • Depend on locality or institution
OVERCROWDING • Different causative factor
1987 – first statewide conference ED
“overcrowding” New York, USA
Nov 2022 – IFEM Global Campaign against ED
Overcrowding overcrowding
Worldwide “The current state of overcrowding experienced at
Hospital Emergency Department in many nation
globally is unacceptable and preventable threat to
patient safety which must be immediately
addressed”
Signs of Overcrowding
Delay in the treatment of patients due to a lack of suitable
spaces
Treatments administered in other spaces of the ED, including
corridors
Prolonged stay of patients in the emergency room at the end
of medical treatment, pending transfer to the ward
Inability to take care of patients transported by ambulance
Obstruction of the entry and exit routes of the ED.
ED Overcrowding Indicator
PATIENT LOS CALL NOT AMBULANCE BOARDING % RESOURCES
AROUND DIVERSION TIME UTILISATION
IMPACT ON SYSTEM
ADVERSE OUTCOME
Increases triage time
Increases waiting time to treatment
Increases length of stay in ED
Decrease quality of care
Increase medication error, delay and omission
Time to thrombolysis, analgesia and
antibiotics
Decrease infection prevention and control
Increase morbidity and mortality
Increase rate of death by 34% at 10 days
for patients who experienced ED
overcrowding during hospitalization
Ambulance diversion
Delayed care for time-critical illnesses :
acute myocardial infarction, acute stroke,
severe sepsis
IMPACT ON PATIENT
Decrease patient satisfaction
Lack of privacy and preservation
of dignity
Increase patients leaving without
being seen
Increase discharge against
medical advice
Patients discharged home despite
high-risk clinical features
IMPACT ON STRUCTURE AND
EQUIPMENT
Waiting halls and corridors being
transformed into makeshift clinical
area
Over utilization of medical
equipment
Ventilators, monitors, infusion
pumps, ultrasound machines
Increase rate of equipment
breakdown
Fastens wear and tear
Over utilization POCT and
consumables
Increase operational cost
IMPACT ON ORGANISATION
Workforce “mismatch”
Causes staff burnout due to high
workload
Increase patients/ relative
violence towards staff due to
frustration
Affects the quality of learning for
young staff (doctor, nurse, etc)
Changing role of ED doctors
From resuscitation and
stabilization to diagnostic,
definitive and de-escalation
theraphy
INPUT - THROUGHPUT - OUTPUT MODEL
Problems Identified Using the Fishbone Analysis
Causative
Factors of
Overcrowding
Input Factor
Patient’s complexity
Increasing geriatric, obese, socially
displaced population
Surge of seasonal illnesses
Example : dengue, covid 19
Patients bypassing appointment-base
clinic for walk-in treatment
Unnecessary ambulance activation by
stable patients
Lower income groups crowded BPJS
hospitals
Limited access to primary care
Non emergent referral
Throughput Factors
Organization & HR System
Inadequate number of staff – staff
Referral
mismatch
Delayed referral from ED doctors
(ED & beyond ED)
Delayed decision making
Inexperienced staff -- high turnover
staff Patients requires assessment
outside ED
Patients
Manual System
Complex cases requires multiple
diagnostic test and treatment Portal system : lab samples,
blood products and imaging
Complex syndrome – multiple
films
referral
Registration
Structure & Equipment
Medical records
Bottleneck point – ECG test
Facility outside ED – x-rays, CT,
endoscopy
Ambulances – intrahospital transfer
Output Factors
Admission System (Process)
• Admission from ED :Unclear criteria, inappropriate admission
• Admission from OPD : unnecessary investigation
Bed Management
• Disintegrated bed management system
• Maldistribution of beds between departments
• Mismatch between high acuity beds availability and demand
Discharge decision and Discharge process
• Late discharge
• Low discharge rate over weekend
• Bed occupied by discharged patients (delayed pick up, homeless)
SOLUTION
Governance
National level
LOCAL solution
Intra department patient management system
Inter department patient management system
Digitalization of medical services
Public – private partnership
Community participant & empowerment
Human resource development & sustainability
Structural capacity improvement
Financial support & sustainability
SOLUTION
Immediate
Factors within ED governance
Intermediate
Involving integration/ collaboration
between departments (hospital
governance)
ICT development
Long term
Additional fund
Policy changes
Structural Development
Assist medical professionals through
the measurement of current ED
Crowding conditions, detection of abnormal ED
scores operations, and anticipation of
increased crowding levels.
Crowding scores
National Emergency Department Overcrowding Scale (NEDOCS)
The Emergency Department Work Index (EDWIN)
The Real-time Emergency Analysis of Demand Indicator (READI)
The Community Emergency Department Overcrowding Scale (CEDOCS)
Emergency Overcrowding Score (EDOS)
CEDOCS
Score
Summary
ED overcrowding must be managed to minimize the impact on patients, staff and the hospital
ED overcrowding scores are a tool to find out and predict the level of crowding, choose scoring level that
suitable for local condition
ED overcrowding occurs worldwide, the problem is universal, the solution must be local
Thank You
