Patients at Risk in Overcrowded Emergency Departments and Hospitals

Two studies conducted in Perth and Canberra provide evidence to support an association between emergency department (ED) overcrowding caused by 'access block' - ED patients waiting 8 hours or more for a hospital bed - and increased mortality.

The Perth study collected data on overcrowding in Perth hospitals and deaths in patients admitted to hospital via the ED between July 2000 and June 2003, analysing more than 60,000 admissions.

The Canberra study, using data from the Canberra Hospital ED in 2002, 2003 and 2004, compared mortality at 10 days in patients presenting to ED during overcrowded periods and equivalent not overcrowded periods.

Both studies showed that patients admitted when the ED was overcrowded were more likely to die.

The Perth study found that patients admitted to hospital via an overcrowded ED had a 30 per cent relative increase in mortality by Day 2 and Day 7, and estimated that 120 deaths were associated with overcrowding in Perth's tertiary hospitals in 2003.

Associate Professor of Emergency Medicine, Dr Peter Sprivulis, head of the Perth study, said the findings suggest that overcrowding should be regarded as a patient safety issue rather than simply an issue of hospital workflow.

"Delays and errors occur more often when systems are stressed by constraining resources, such as when a hospital is overcrowded," Professor Sprivulis said.

"Overcrowding is often associated with placing inpatients on an incorrect ward - such as medical patients placed in emergency department corridors, which can cause potential adverse events.

"Patients who died who attended during overcrowded conditions experienced delays in transfer to an inpatient bed and may have suffered delays in urgently needed treatment," Professor Sprivulis said.

So, does the solution to this problem lie simply with an increase in hospital beds?

Not necessarily, says Professor Peter Cameron of Monash University, in an editorial accompanying the two studies.

"It is important to note that access block does not correlate well with the absolute number of hospital beds," Professor Cameron says.

"Increasing the number of hospital beds temporarily alleviates access block, but does not solve the problem - the beds quickly fill and the problem recurs."

The solution to alleviating access block, and addressing the associated mortality risks, seem most likely to be found in improved management of patients and a more skilled health workforce.

Professor Cameron says health care workers efforts to increase capacity by improved efficiency of health care delivery are already bringing benefits, but further improvements will need major investments in infrastructure, especially information technology.

"Workforce reform is necessary to increase the flexibility of the workforce and the capacity of the health care system.

"There is presently a shortage of virtually every type of skilled worker in the health care sector," says Professor Cameron.

Balancing elective and emergency workloads and introducing better discharge systems are also identified by Professor Cameron as ways of reducing access block.

"Moving patients quickly from acute hospitals to more appropriate facilities increases hospital bed availability.

"Access to rehabilitation, residential aged care and community outreach programs is an essential component of an efficient and well managed health system," he says.

Professor Sprivulis said hospital overcrowding is a complex phenomenon.

"Overcrowding may rise in health services in developed economies as age-related demand for hospital services grows over the next 10-15 years," Professor Sprivulis said.

"Economic incentives tend to favour high occupancy, and solutions may include the realignment of incentives that favour a high level of hospital occupancy at the expense of emergency access.

"Strategies that reduce waste, misuse and overuse of health services, and improved chronic disease management to reduce hospital demand, are needed. Also required are better matching of bed supply with predictable emergency demand and optimisation of hospital inpatient flow."

Associate Professor Drew Richardson, Chair of Road Trauma and Emergency Medicine at Canberra Hospital, and author of the Canberra study, says further studies were needed to fully understand the problem of overcrowding and increased mortality.

In the Canberra study, patients presenting when the ED was overcrowded had a significantly higher death rate in hospital at 10 days than those treated when the ED was not overcrowded.

The patients arriving when the ED is overcrowded may receive a lower quality of care because the available resources are stretched too thinly. However, it is also possible a 'sicker' group of patients contributed to both overcrowding and to higher mortality rates.

Professor Richardson says ED overcrowding is caused by insufficient available beds, and it is also plausible that the situation in the ED represents a marker of global hospital dysfunction and that some deaths are related to inpatient issues such as inappropriate discharge or admission to an 'outlier' ward (as opposed to the 'home' ward where staff are experienced in the relevant specialty).

"The magnitude of the association of overcrowding and mortality in the ACT is around 13 excess in-hospital deaths annually," says Professor Richardson.

"That's similar to the number of people killed on the roads in the ACT each year, and if replicated in other studies, this association would represent a significant public health issue."

The Medical Journal of Australia is a publication of the Australian Medical Association.