Patient Safety and Quality
Background: ED congestion is an ongoing threat to quality care. Traditional measures of ED efficiency use census and wait times over extended time intervals (e.g. per year, per day), failing to capture important hourly variations in ED flow. Borrowing from the traffic theory framework used to describe cars on a freeway, ED flow can instead be characterized by three fundamental parameters: flux (patients traversing a care segment per unit time), density (patients in a care segment per unit time), and duration (length of stay in a care segment). This method allows for the calculation of near-instantaneous ED flux and density. To illustrate, we examined the association between stretcher occupancy and time to physician initial assessment (PIA), seeking to identify thresholds where flux and PIA deteriorate.
Methods: We used administrative data as reported to government agencies for 115,559 ED visits from April 1, 2014 to March 31, 2016 at a tertiary academic hospital. Time stamps collected at triage, PIA, and departure were verified by nosologists and used to define two care segments: awaiting assessment or receiving care. Using open-source software developed in-house, we calculated flow measures for each segment at 90-minute intervals. Graphical analysis was supplemented by regression analysis, examining PIA times of high (CTAS 1-3) or low (CTAS 4-5) acuity patients against ED occupancy (=density/staffed stretchers) adjusting for day of week, season and fiscal year.
Results: Below 50% occupancy, PIA times are stable and flux increases with density, reflecting free flow. Above 50% occupancy, PIA times increase linearly and flux plateaus, indicating congestion. As PIA times further deteriorate above 100% occupancy, flow is maintained, showing care delivery in non-traditional spaces (e.g. hallways). An inflection point where flux decreased with increased crowding was not identified, despite lengthening queues.
Conclusion: ED performance can be characterized with traffic engineering techniques. Unlike a jammed roadway, ED care continues despite substantial crowding. Nevertheless, congestion begins well below 100% occupancy, presumably reflecting the need for stretcher turnover and saturation in subsegmental work processes. This methodology shows promise to model, analyze and mitigate the many factors contributing to ED crowding.