Differences and Similarities in Emergency Department Crowding Between a Developing Country and a Developed Country

Purpose: Emergency department (ED) crowding is an international crisis affecting patient care. ED crowding is associated with delays in treatment, diminished quality of care, and increased inpatient mortality. The problem of ED crowding has been extensively described in hospitals in the USA, Canada, Australia and Europe. However, the problem is not limited to developed countries. Although no comparison has been made between crowding issues in developed versus developing countries, lower amounts of resources may result in more severe crowding in developing countries. In this study, patient flow was compared between a hospital in a developing country, and a hospital in a developed country. Identifying key issues and bottlenecks affecting ED patient flow and analyzing the relative importance of contributing factors may provide insight into promising solutions.

Methods:

An IRB-approved mixed methods study was conducted at two EDs, both urban Level 1 Trauma Centers. First, a 1-year (August 2014 – July 2015) retrospective cohort study was performed, comparing patients’ conditions (including acuity level and final disposition) and crowding measures (including length of stay). Acuity level was registered according to the 5-level triage scales used at the EDs, in which acuity 1 has the highest priority and 5 the lowest priority. To investigate differences and similarities in the quantitative data between the hospitals, we used two-tailed t tests, Mann Whitney U tests, and c² tests where appropriate. Statistical significance was assumed at a level of P < 0.05.

Second, participant observation and 18 face-to-face interviews were conducted in August and September 2015, focusing on the causes and consequences of ED crowding. Hospital administrators, ED staff, nurse managers, and emergency physicians were questioned individually about what they considered to be the main causes and consequences of ED crowding, using open-ended questions. Observation notes and interviews were transcribed within 12 hours. A member check technique with ED management was used to verify the accuracy and validity of the observations. Qualitative content analysis was used to summarize the views of the interviewees regarding causes and consequences of ED crowding into input-, throughput- and output issues. Analysis of the observations continued with triangulation from other sources (including scientific articles regarding ED crowding).

Results:

At the ED in the developing country 58,839 visits (160 patients/day), and at the ED in the developed country 50,802 visits (140 patients/day) were registered. Patients’ conditions and ED crowding were worse in the developing country compared with the developed country. Median patient length of stay at the ED of the developing country was significantly longer (279 minutes vs. 100 minutes, P<0.001). Length of stay exceeded 6 hours for 37.9% of the patients at the ED in the developing country, vs. 3.3% of the patients at the ED in the developed country (P<0.001). Almost 17% of the patients of the ED in the developing country were assigned acuity level 1, while only 1% of the ED patients in the developed country were assigned acuity level 1. There were higher admission percentages (35% vs. 21%, P<0.001) and higher mortality rates (1.4% vs. 0.1%, P<0.001) at the ED in the developing country compared with the ED in the developed country.

According to the interviewees from both EDs, crowding occurs on a daily basis. Interviewees mentioned similar reasons for constraints to the patient flow: high patient volumes, long treatment times, and poor availability of inpatient beds. An important reason for long length of stays at the ED of the developing country was the delay in reaching a decision to admit the patient or send the patient home. At both hospitals, delays in the admitting process, mostly due to a shortage of inpatient bed capacity, were mentioned. Solutions to ED crowding in the developing country should focus on improving ED throughput as well as ED output, while at the ED in the developed country the output issues are more important.

Conclusion:

Despite differences in patient populations (more severely sick at the ED in the developing country), and in the state of crowding (worse at the ED in the developing country), the causes of ED crowding were the same in both EDs: high volumes, long treatment times, and poor availability of inpatient beds. ED crowding in the developing country can be reduced by more efficient processes in the ED and by increased capacity within the hospital. At the ED in the developed country, the outflow should be improved.

The impact of new interventions to improve patient flow through the ED should be considered carefully. Monitoring the patient flow during a longer period of time allows assessment of the extent to which these interventions foster constructive change.