Naomi van der Linden

Emergency department crowding in the Netherlands: Managers' experiences

BackgroundIn The Netherlands, the state of emergency department (ED) crowding is unknown. Anecdotal evidence suggests that current ED patients experience a longer length of stay (LOS) compared to some years ago, which is indicative of ED crowding. However, no multicenter studies have been performed to quantify LOS and assess crowding at Dutch EDs. We performed this study to describe the current state of emergency departments in The Netherlands regarding patients’ length of stay and ED nurse managers’ experiences of crowding.MethodsA survey was sent to all 94 ED nurse managers in The Netherlands with questions regarding the type of facility, annual ED census, and patients’ LOS. Additional questions included whether crowding was ever a problem at the particular ED, how often it occurred, which time periods had the worst episodes of crowding, and what measures the particular ED had undertaken to improve patient flow.ResultsSurveys were collected from 63 EDs (67%). Mean annual ED visits were 24,936 (SD ± 9,840); mean LOS for discharged patients was 119 (SD ± 40) min and mean LOS for admitted patients 146 (SD ± 49) min. Consultation delays, laboratory and radiology delays, and hospital bed shortages for patients needing admission were the most cited reasons for crowding. Admitted patients had a longer LOS because of delays in obtaining inpatient beds. Thirty-nine of 57 respondents (68%) reported that crowding occurred several times a week or even daily, mostly between 12:00 and 20:00. Measures taken by hospitals to manage crowding included placing patients in hallways and using fasttrack with treatment of patients by trained nurse practitioners.ConclusionsDespite a relatively short LOS, frequent crowding appears to be a nationwide problem according to Dutch ED nurse managers, with 68% of them reporting that crowding occurred several times a week or even daily. Consultations delays, laboratory and radiology delays, and hospital bed shortage for patients needing admission were believed to be the most important factors contributing to ED crowding.

Rate, characteristics, and factors associated with high emergency department utilization

BackgroundPatients with high emergency department (ED) utilization account for a disproportionate number of ED visits. The existing research on high ED utilization has raised doubts about the homogeneity of the frequent ED user. Attention to differences among the subgroups of frequent visitors (FV) and highly frequent visitors (HFV) is necessary in order to plan more effective interventions.In the Netherlands, the incidence of high ED utilization is unknown. The purpose of this study was to investigate if the well-documented international high ED utilization also exists in the Netherlands and if so, to characterize these patients. Therefore, we assessed the proportion of FV and HFV; compared age, sex, and visit outcomes between patients with high ED utilization and patients with single ED visits; and explored the factors associated with high ED utilization.MethodsA 1-year retrospective descriptive correlational study was performed in two Dutch EDs, using thresholds of 7 to 17 visits for frequent ED use, and greater than or equal to 18 visits for highly frequent ED use.ResultsFV and HFV (together accounting for 0.5% of total ED patients) attended the ED 2,338 times (3.3% of the total number of ED visits). FV and HFV were equally likely to be male or female, were less likely to be self-referred, and they suffered from urgent complaints more often compared to patients with single visits. FV were significantly older than patients with single visits and more often admitted than patients with single visits. Several chief complaints were indicative for frequent and highly frequent ED use, such as shortness of breath and a psychiatric disorder.ConclusionsBased on this study, high ED utilization in the Netherlands seems to be less a problem than outlined in international literature. No major differences were found between FV and HFV, they presented with the same, often serious, problems. Our study supports the notion that most patients with high ED utilization visit the ED for significant medical problems.

Evaluation of a Flexible Acute Admission Unit: Effects on Transfers to Other Hospitals and Patient Throughput Times

INTRODUCTION To prevent overcrowding of the emergency department, a flexible acute admission unit (FAAU) was created, consisting of 15 inpatient regular beds located in different departments. We expected the FAAU to result in fewer transfers to other hospitals and in a lower length of stay (LOS) of patients needing hospital admission. METHODS A before-and-after interventional study was performed in a level 1 trauma center in the Netherlands. Number of transfers and LOS of admitted ED patients in a 4-month period in 2008 (control period) and a 4-month period in 2009 (intervention period) were analyzed. RESULTS Of 1,619 regular admission patients, 768 were admitted in the control period and 851 in the intervention period. The number of transfers decreased from 80 (10.42%) to 54 (6.35%) (P = .0037). The mean ED LOS of both the non-admitted patients and the admitted patients needing special care significantly increased (105 minutes vs 117 minutes [P = .022] and 176 minutes vs 191 minutes [P < .001], respectively). However, the mean LOS of FAAU-admissible patients was unaltered (226 minutes vs 225 minutes, P = .865). CONCLUSIONS The FAAU reduced the number of transfers of admitted patients to other hospitals. The increase in LOS for special care patients and non-admitted patients was not observed for regular, FAAU-admissible patients. Flexible bed management might be useful in preventing overcrowding.

Effects of emergency department crowding on the delivery of timely care in an inner-city hospital in the Netherlands

Background The impact of delays in emergency department (ED) care has not been described in European countries where ED crowding is not universally recognized. The aim of this study was to determine the relationship of ED crowding with delays in triage and treatment, and 24-h mortality in patients admitted to the ED. Methods Five years of data from adults admitted to the hospital were analysed retrospectively from an inner-city ED in the Netherlands. Variables included the following: crowded versus noncrowded time, time to triage, triage category, time to treatment, age, 24-h mortality and 10-day mortality. Results A total of 39 110 patients met the inclusion criteria. ED crowding occurred 30.8% of the time. There were no differences in mortality between patients arriving during crowding versus those arriving during noncrowding. Delays in triage during ED crowding occurred 29.7% of the time versus 14.6% during noncrowding. Delays in treatment occurred 11.7 and 7.3% of the time during crowding and noncrowding, respectively. Conclusion In this hospital, ED crowding results in increased times to triage and to treatment, not in increased 24-h or 10-day mortality.

Walkouts from the emergency department: characteristics, reasons and medical care needs.

Objectives The aim of this study was to assess the walkout rate and to identify influencing patient and visit characteristics on walkout. Furthermore, we assessed the reasons for leaving and medical care needs after leaving. Methods In a 4-month population-based cohort study, the characteristics and influencing factors of walkout from two emergency departments in the Netherlands were studied. Afterwards, a follow-up telephone interview was conducted to assess the reasons for leaving and medical care needed. Results A total of 169 out of 23 780 (0.7%) registered patients left without treatment, of whom 62% left after triage. Of the triaged walkouts, 26% had urgent or highly urgent medical complaints and target times to treatment had elapsed for 54% of the triaged walkouts. Independent predictors of leaving without treatment included being self-referred, arriving during the evening or night or during crowded conditions, and relatively lower urgency triage allocation. Ninety (53%) walkouts were contacted afterwards by phone. Long waiting time (61%) was the most-cited prime reason for leaving. Medical problems had resolved spontaneously in 19 of the 90 (21%) walkouts, and 47 (52%) walkouts reported having sought medical care elsewhere. For 24 of the 90 (27%) walkouts with persisting complaints, medical care was advised during the follow-up telephone call. Conclusion The average observed daily walkout rate was 1.4 patients over the 4-month period. In general, walkouts are self-referrals with lower urgent complaints, arriving during the evening or night shift or during crowded conditions. Most walkouts leave because of perceived long waiting times.

The impact of medical specialist staffing on emergency department patient flow and satisfaction

Objective The aim of this study was to describe the impact of additional medical specialists, non-emergency physicians (non-EPs), performing direct supervision or a combination of direct and indirect supervision at an EP-led emergency department (ED), on patient flow and satisfaction. Patients and methods An observational, cross-sectional, three-part study was carried out including staff surveys (n=379), a before and after 16-week data collection using data of visits during the peak hours (n=5270), and patient questionnaires during 1 week before the pilot and during week 5 of the pilot. Content analysis and descriptive statistics were used for analyses. Results The value of being present at the ED was acknowledged by medical specialists in 49% of their surveys and 35% of the EPs’ and ED nurses’ surveys, especially during busy shifts. Radiologists were most often (67.3%) convinced of their value of being on-site, which was agreed upon by the ED professionals. Perceived improved quality of care, shortening of length of stay, and enhanced peer consultation were mentioned most often. During the pilot period, length of stay of boarded patients decreased from 197 min (interquartile range: 121 min) to 181 min (interquartile range: 113 min, P=0.006), and patient recommendation scores increased from −15 to +20. Conclusion Although limited by the mix of direct and indirect supervision, our results suggest a positive impact of additional medical specialists during busy shifts. Throughput of admitted patients and patient satisfaction improved during the pilot period. Whether these findings differ between direct supervision and combination of direct and indirect supervision by the medical specialists requires further investigation.

Real-world costs of laboratory tests for non-small cell lung cancer

*Corresponding author: Naomi van der Linden, MSc, Institute for Medical Technology Assessment (iMTA), Erasmus University Rotterdam, Woudestein location, J5-51, PO Box 1738, 3000 DR Rotterdam, The Netherlands, Phone: +31 10 4088886, Fax: +31 10 4089081, E-mail: vanderlinden@bmg.eur.nl Egbert F. Smit: Department of Pulmonary Diseases, VU Medical Centre, Amsterdam, The Netherlands Carin A. Uyl-de Groot: Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands Letter to the Editor