Effects of a hospital-wide intervention on emergency department crowding and quality: A prospective study

Objective: The objective of this study was to determine the impact of a management-supported, multimodal, hospital-wide intervention on ED crowding and quality measures. Methods: This is a prospective descriptive study of the first 20 weeks of the intervention, with 3 years of historical controls. The study was conducted in a 600 bed adult/paediatric tertiary hospital with 80 000 ED presentations annually. ED information system data were collected on all presentations in matched 20 week periods. Multiple interventions included ED Navigator role, ED Medical Staff teaming, corporate focus with key performance indicators and dashboards, appointment of a Director of Operations, Long Length of Stay Committee and reorganisation of the flow (bed management) unit. Process outcomes were 4 h performance as a proportion of all patients and mean daily length of crowding with more than 10 inpatients awaiting beds expressed as a time. Quality outcomes were proportions of patients who did not wait and who re-presented within 72 h. Results: There was a 9.1% increase in presentations and a 22.6% decrease in mean ED occupancy over the previous year. The 4 h performance improved from 56.1% (95% confidence interval [CI] 55.5–56.7) to 68.8% (95% CI 68.3–69.3) and daily crowding with more than 10 inpatients improved from 6:34 (95% CI 5:32–7:37) to 0:29 (95% CI 0:15–0:42). Did not wait improved significantly from 5.1 to 3.0% and rate of representation did not change. Conclusion: This prospective study shows significant improvement in ED flow without compromise in quality measures from a hospital-wide intervention requiring minimal additional resources. Further research is required on sustainability and patient outcomes beyond the ED.