HOSPITAL KATH BY DR NANA SERWAA A QUAO OVERCROWDING IN THE EMERGENCY DEPARTMENT ED DR GEORGE ODURO DR JOE BONNEY DR PAA KOBINA FORSON COAUTHORS INTRODUCTION PURPOSE OBJECTIVE METHOD ID: 618167
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PERCEPTION BY HEALTH WORKERS IN THE ACCIDENT AND EMERGENCY CENTRE, KOMFO ANOKYE TEACHING HOSPITAL (KATH)BYDR. NANA SERWAA A. QUAO
OVERCROWDING IN THE EMERGENCY DEPARTMENT (ED):Slide2Slide3
DR. GEORGE ODURO
DR. JOE BONNEY
DR. PAA KOBINA FORSON
CO-AUTHORSSlide4
INTRODUCTIONPURPOSE
OBJECTIVE
METHOD
SAMPLE
RESULTS
DISCUSSIONRECOMMENDATIONCONCLUSIONREFERENCES
OUTLINESlide5
Emergency department (ED) overcrowding is gradually becoming a growing trend in many hospitals worldwide.
According to a 2002 national US survey, more than 90% of large hospitals report EDs operating “at” or “over” capacity.
Overcrowding can be defined as “a situation in which demand for service exceeds the ability to provide care within a reasonable time, causing physicians and nurses to be unable to provide quality care”.
INTRODUCTIONSlide6Slide7Slide8Slide9Slide10
A number of effects have resulted from ED overcrowding:Inadequate patient care
Prolonged delays in the treatment of pain and suffering
Long waiting times and patient dissatisfaction
Ambulance diversions
Decreased nurse/physician satisfaction
Negative effect on teaching and research
(Canadian Association of Emergency Physicians,
CJEM (2001
)).Slide11
KATH ED receives an average of 84 patients per day and 28,000 patients in a year.
Overcrowding
and long boarding hours has been a challenge in the EDSlide12Slide13
To assess the perception and causes of patient overcrowding among health personnel and to identify strategies to reduce overcrowding in the emergency department.
PURPOSE OF THE STUDYSlide14
To determine the perception of overcrowding in the emergency department among health personnel
To identify the factors contributing to overcrowding in the emergency department
To ascertain the effects of overcrowding on patient care among health personnel
To identify strategies to reduce patient overcrowding in the emergency department
SPECIFIC OBJECTIVESSlide15
A cross-sectional study was used.
The study was carried out for three months in 2015.
Questionnaire based interviews were conducted among health workers to give their perception about patient overcrowding and its effects.
Analysis was done using
Epi
Info 7 by CDC.METHODSlide16
A total of 513 health workers (47 doctors, 189 nurses, 277 clinicians in internal medicine, surgery, trauma and orthopaedics, EENT combined) work in the Emergency units of yellow, red, orange and CDU under the Emergency Department.
110 ED health care workers were recruited using systematic random sampling.
SAMPLESlide17
A total of 110 health workers were surveyed with 59 (53.64%) being nurses and 51(46.36%) as doctors.
Females were 52(47.27%) and males were 58 (52.73%).
All workers had attained some form of level of education with Diploma as the highest, 41(42.27%).
Majority of the respondents were residents, 21(19.44%), senior nursing officers, 20(18.52%), and house officers, 14912.96%).
RESULTSSlide18
VARIABLE (N)
Frequency
Percent
SEX (N=110)
MALE
58
52.73%
FEMAE
52
47.27%
AGE (N=96)
20-29
41
42.71%
30-39
49
51.04%
40-49
5
5.21%
50-59
1
1.04%
OCCUPATION (N=110)
NURSING
5953.64%MEDICAL DOCTOR5146.36%EDUCATIONAL LEVEL (N=97) DIPLOMA4142.27%UNIVERSITY UNDERGRADUATE3536.08%TERTIARY1111.34%POST GRADUATE77.22%MGCS22.06%CERTIFICATE11.03%
Source: Field Data, 2015
UNIVARIATE ANALYSIS OF HEALTH WORKERSSlide19
RESULTS
The average waiting time of a patient at the ED as perceived by the health workers was 30minutes before being seen by a physician.
Health personnel thought that there was not much variation in the days when the ED is overcrowded but agreed afternoon shifts were mostly crowded among all shifts. Slide20
Source: Field Data, 2015Slide21
RESULTSHealth personnel most agreed strongly that
inappropriate referrals 59.63%
and
delays in getting radiological imaging 49.07% were the main causes of overcrowding.Slide22
CAUSES OF OVERCROWDING
Table 4.1.3 CAUSES OF OVERCROWDING
VARIABLE
STRONGLY AGREE
AGREE
INDIFFERENT
DISAGREE
STRONGLY DISAGREE
FREQ
%
FREQ
%
FREQ
%
FREQ
%
FREQ
%
Lack of Hospital beds (106)
30
28.30%
34
32.08%
10
9.43%
16
15.09%
16
15.09%
Inappropriate Referrals (109)
65
59.63%2926.61%54.59%87.34%21.83%Patients who come without referrals (105)4038.10%2523.81%1918.10%1615.24%54.76%Inadequate Personnel/staff(107)
32
29.91%
31
28.97%
14
13.08%
21
19.63%
9
8.41%
Inadequate logistics and tools (108)4440.74%4339.81%76.48%1211.11%21.85%Radiology Delays (108)5349.07%4440.74%65.56%54.63%00.00%Laboratory Delays (106)3734.91%4441.51%109.43%1413.21%10.94%Delays in dispensing drugs (108)1715.74%4137.96%2220.37%2725.00%2725.00%Theatre Delays (107)4037.38%4441.12%1413.08%98.41%00.00%Delays in transporting patients (108)3229.91%3128.97%1413.08%2119.63%98.41%Delays in billing or assessments (108)3027.78%4238.89%1614.81%1917.59%10.93%
Source: Field Data, 2015Slide23
NEGATIVE EFFECTS OF OVERCROWDING ON PATIENT CARE
Table 4.1.4
NEGATIVE EFFECTS
OF OVERCROWNDING ON PATIENT CARE
VARIABLE (N=108)
STRONGLY AGREE
AGREE
INDIFFERENT
DISAGREE
STRONGLY DISAGREE
FREQ
%
FREQ
%
FREQ
%
FREQ
%
FREQ
%
INCREASED DELAY IN CLINICAL ASSESSMENT
52
48.15%
44
40.74%
7
6.48%
5
4.63%
0
0.00%
INCREASED MARGIN OF MEDCAL ERROR3532.41%5147.22%98.33%1312.04%00.00%INCREASED STAFF STRESS7771.30%2926.85%21.85%00.00%00.00%
POOR WORK SATISFACTION62
57.41%
37
34.26%
7
6.48%
2
1.85%
0
0.00%
Source: Field Data, 2015Slide24Slide25
Majority of the health workers (95%), said that overcrowding in the ED contributed to poor patient outcome.
Ways in which health workers think overcrowding contribute to poor patient outcome include:
staff exhaustion (40.37%),
compromised quality of patient care (36.70%),
standard procedures not followed
(36.70%),
long waiting time of patients before being assessed by a physician
(29.36%) and
poor working conditions
(27.52%).Slide26
VARIABLE
FREQUENCY
PERCENTAGE
Long Waiting Time
32
29.36%
Logistics Not Enough
17
15.60%
Poor Health Worker Concentration
30
27.52%
Staff Exhaustion
44
40.37%
Can’t Explain
17
15.60%
Cross Infections
28
25.69%
Preventable Poor Outcome
28
25.69%
Standard Procedure Not Followed
40
36.70%
Quality of Care Compromised
40
36.70%
Don’t know
32.75%EFFECTS OF OVERCROWDING ON POOR PATIENT OUTCOMESource: Field Data, 2015Slide27
RESULTS
Health personnel strongly agreed that
Equipping district hospitals to handle non-emergency cases (77.78%),
Appropriate referral system (75.93%),
Provision of adequate logistics and consumables (57.41%) can help curb the problem of overcrowding.Slide28
Table 4.1.5
STRATEGIES
TO REDUCE PATIENT OVERCROWDING
VARIALE (N=)
STRONGLY AGREE
AGREE
INDIFFERENT
DISAGREE
STRONGLY DISAGREE
FREQ.
%
FREQ.
%
FREQ.
%
FREQ.
%
FREQ.
%
INCREASE NUMBER OF PERSONNEL (106)
28
26.42%
45
42.45%
13
12.26%
14
13.21%
6
5.66%
INCREASE NUMER OF BEDS (106)3129.25%2018.87%1312.26%3129.25%1110.38%INCREASE THEATRE SPACE (108)3229.63%4238.89%1715.74%1412.96%32.78%BUILD MORE EMERGENCY CENTRES (108)
6459.26
31
28.70%
7
6.48%
4
3.70%
2
1.85%
EQUIP DITRICT HOSPITALS TO HANDLE NON EMERGENCY CASES (108)
8477.78%2323.00%00.00%00.00%10.93%APPROPRIATE REFERRAL SYSTEM (108)8275.93%2523.15%00.00%10.93%00.00%BED MANAGER POSITION (107)4844.86%3936.45%1514.02%54.67%00.00%PROVISION OF ADEQUATE LOGISTICS AND CONSUMABLES (108)6257.41%3835.19%43.70%43.70%00.00%Source: Field Data, 2015Slide29
RESULTS
A greater number of the respondents (98%) agreed that information about bed state on the wards should be sent to the ED as a means of reducing overcrowding whiles 2% thought it was not a good idea.
Those who agreed, majority responded that ward bed states should be sent every
six hours
(four times) in a day.Slide30
VARIABLE (N)
FREQUENCY
PERCENTAGE
PHONE CALL (48)
47
31.97%
TEXT MESSAGE (34)
34
18.18%
PHYSICALY GOING UP TO CHECK (34)
33
17.64%
MOBILE APP/ SOFTWARE (63)
63
33.68%
ALL OPTIONS ABOVE (10)
10
5.34%
Best ways identified to send ward bed state information to the
ward
Source: Field Data, 2015Slide31
Mobile Phone Application On An Android PhoneSlide32
VARIABLE (N=43)
FREQUENCY
PERCENTAGE
Help Reduce Overcrowding
8
14.04%
Fast Way to Disseminate Bed State
13
22.81%
Software Is Good and Effective
19
33.33%
Will Not Change Situation
3
5.26%
Benefits For Using Mobile Phone Technology
Source: Field Data, 2015Slide33
VARIABLE(N=54)
FREQUENCY
PERCENTAGE
ADVANTAGES
Effective and quick means for checking and transferring patients to the main wards
21
38.89%
Speed up patient recovery
1
1.85%
Easiest way for information Dissemination about updates of bed state
13
24.07%
Easier and convenient
6
11.11%
Reduces work load at emergency Unit
2
3.70%
DIASADVANTAGES
Information is not accurate
7
12.96%
Does not make any difference
2
3.70%
Increase Inefficiency of personnel
2
3.70%
PROS AND CONS OF USING MOBILE PHONE TECHNOLOGY
Source: Field Data, 2015Slide34
The average waiting time to see a physician is 30 minutes in the ED compared to……
KATH-A
& E is the only
tertiary centre serving the Northern zone of the country and therefore the only one providing specialist services in addition to normal OPD services.
The impact of nearby district hospitals on overcrowding in a Tertiary centre
Overuse of equipment and resources in the hospital
Health
workers are usually tired, exhausted and fatigued so much
that there
can be errors leading to increased morbidity and mortality
DISCUSSIONSlide35
There is a need to put in measures to curb overcrowding.
One
way of curbing overcrowding is to enhance patient outflow from the ED.
A
number of hospitals have implemented patient flow improvement strategies that have resulted in reductions in measures of ED crowding.
As a result, numerous organizations—including the Institute for Healthcare Improvement, the Joint Commission, and the Institute of Medicine—have encouraged hospital leaders to adopt patient flow improvements. (Mcghuh
, 2011)
DISCUSSIONSlide36
DISCUSSION
Contacting doctors on phones to review
patient
Bed
managers have been
introducedReal-time monitoring of patient flow via the use of a mobile phone software application.It
involves the integration of information technology to aid the monitoring of bed states and patient transfers (
Theummler
et al, 2005
).Slide37
RECOMMENDATIONS
Internal Emergency Department
Actions and
Processes That Will Improve Access and Flow:Develop a fast track for treating simple
fractures, lacerations
, sore throats, etc.Minimize silos within the department.Expand the practice of observation medicine.Implement triage protocols.
Expand
the size of
the ED
Provide
additional staff during times of increased volume.
Examine
the discharge process and measure
all reasons
for delays in discharge of the
patient.
Establish
hospital-wide protocols for
addressing capacity
issues in the emergency
department and
implement an alert system when
the hospital
is over capacity
. ACEP 2007Slide38
RECOMMENDATIONS
Expansion and equipping of existing health facilities to manage non emergency cases/ OPD
to reduce
the number of patients waiting in tertiary centres.
Increase
access to immediate diagnostic testing (e.g., ultrasonography, CT scans, MRI) and laboratory investigations to improve patient flow.Slide39
CONCLUSIONOvercrowding
in the ED is perceived to cause staff burn-out and result in poor patient outcomes. Evidence-based interventions may improve
overcrowding. Slide40
Cowan, R.M. & Trzeciak, S., 2005. Clinical review: Emergency department overcrowding and the potential impact on the critically ill.
Critical care (London, England)
, 9(3), pp.291–5. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15987383 [Accessed August 10, 2016
].Joint
Position Statement on emergency department overcrowding. CJEM [Internet]. 2001 Apr 21 [cited 2016 Aug 12];3(2):82–4. Available from:
http://www.journals.cambridge.org/abstract_S1481803500005285Forson PK (2011). An audit of emergency care at the Accident and Emergency Unit of KATH, Kumasi, Ghana. Masters Thesis Community Health Department, KNUST, Kumasi. (Unpublished)
Mchugh
, M. & Dyke, K.V., 2011. and Reducing Emergency Department Crowding : A Guide for Hospitals Improving Patient Flow Department Crowding : improving Patient Flow and Reducing Emergency Department Crowding, p.8.
REFERENCESSlide41