The hospital emergency department (ED) is a critical source for health care amid a complex healthcare system in the United States. It is the gateway to care for a broad range of people, arriving from a variety of locations. With this wide reaching net and a decreasing trend in hospital beds, EDs throughout the United States are experiencing overcrowding. ED crowding has various tactical and strategic facility management impacts ranging from facility occupancy issues to adverse health outcomes. Among other factors, recent research has cited the sharp increase in ED visits over the years and ED patient boarding as key contributors to crowding. Home hospital care is a model in which health care is delivered at an individual’s home as a substitute for hospital-level inpatient short-term acute care. Clinical research has shown home hospital to be an effective care model for select illnesses presenting frequently to EDs, such as congestive heart failure, community acquired pneumonia, chronic obstructive pulmonary disease, and cellulitis. While there exist distinct clinical and social criteria for which delineate eligible individuals, home hospital care models have been linked with the potential to free inpatient beds. The overarching objective of this study is to investigate the relationship between home hospital care and ED crowding. To achieve this objective, the study examined the relationship between home hospital care and ED crowding, specific to ED boarding performance at a large, urban, teaching hospital facility. A methodology for identification of potential home hospital patients was used through clinical and social criteria, and a scale for the range of clinical eligibility rates was established for the five suitable illnesses. The study modeled patient flow and bed demand, and utilized computer simulation modeling to assess the impact of home hospital care on ED boarding performance. Various models were simulated to represent different home hospital intervention types. The models incorporated home hospital through an ED Referral program, Inpatient-Transfer Referral program, Community Referral program, and a fully integrated home hospital program. Three scenarios were run for each model to assess practical possibilities for the utilization of the freed bed hours from a home hospital program. This research contributes insight and understanding of home hospital’s impacts on ED crowding. The insight from this study quantifies the effects of a home hospital program on ED boarding and inpatient bed demand. The modeling study is contributes an analytical understanding of the impacts that home hospital could potentially have on crowding, which could prove useful in the struggle against ED congestion. This understanding helps to provide a more thorough understanding of home hospital, and could aid in an organization’s decision-making process of whether to implement a program. The presented modeling methodology for analyzing home hospital and ED crowding can also be used as a model format for researchers and practitioners for analytical purposes in future studies.

Healthcare industry in United States of America is facing a big paradox. Although US is a leader in the industry of medical devices, medical practices and medical researches, however there isnt enough satisfaction and quality in performance of US healthcare operations. Despite the big investments and budgets associated with US healthcare, there are big threats to US healthcare operational side, that reduces the quality of care. In this research study, a step by step Systems Engineering approach is applied to improve healthcare delivery process in an Emergency Department of a hospital located in Indianapolis, Indiana. In this study, different type of systems engineering tools and techniques are used to improve the quality of care and patients satisfaction in ED of Eskenazi hospital. Having a simulation model will help to have a better understanding of the ED process and learn more about the bottlenecks of the process. Simulation model is verified and validated using different techniques like applying extreme and moderate conditions and comparing model results with historical data. 4 different what if scenarios are proposed and tested to find out about possible LOS improvements. Additionally, those scenarios are tested in both regular and an increased patient arrival rate. The optimal selected what-if scenario can reduce the LOS by 37 minutes compared to current ED setting. Additionally, by increasing the patient arrival rate patients may stay in the ED up to 6 hours. However, with the proposed ED setting, patients will only spend an additional 106 minutes compared to the regular patient arrival rate.<br>

The problem of overcrowding is one of the serious issues that almost every emergency department (ED) in Taiwan has to face on daily basis. ED crowding results in adverse medical outcomes, decline in quality of care, and lack of the ability to provide instant medical care. One of the viable (but not necessarily preferable) solutions to ED overcrowding is ambulance diversion (AD). That is, ambulances would bypass the ED¡¦s unable to provide emergency medical service, and send patients to another emergency department. In many medical systems, ambulance diversion is being seen as a standard operating procedure, whose effectiveness needs to be carefully studied before making a sound policy. In this research, an input-throughput-output simulation model is proposed for simulating ED operation. A computer simulation program is developed based on this model to evaluate various AD initiating criteria, patient-blocking rules, and AD intervals. The crowdedness index, the patient waiting time for service, and the percentage of adverse patients were assessed to determine the impact of various AD policies. By appropriate parameter settings, this simulation model can represent medical resource providers of different scales. The results we obtained may offer insights for making effective AD policies.

Reducing ED wait times is a top health care priority for the Ontario government and hospitals in Ontario are incentivised to meet provincial ED wait time targets. In this study, we considered the costs and benefits associated with increasing the number of acute-care beds to reduce the time an admitted patient spends boarding in the ED. A shorter hospital LOS has often been cited as a potential benefit associated with shorter ED wait times. We derived a multivariable Cox regression model to examine this association. We found no significant association between ED boarding times and the time to discharge. Using a Markov model, we estimated an increased annual operating cost of $2.1m to meet the prescribed wait time targets. We concluded that increasing acute-care beds to reduce ED wait times would require significant funding from hospitals and would have no effect on total length of stay of hospitalized patients.

The emergency department (ED) has often been considered the safety net of the American healthcare system. It earned this distinction because every person in the United States has access to a medical screening exam and stabilization at an ED regardless of their ability to pay. Unfortunately, over the past several decades, decreasing numbers of EDs and inpatient beds, coupled with increasing rates of ED usage, has led to crowding of EDs across the country. Crowding leads to unsafe conditions that may increase morbidity and mortality for patients, or cause patients to leave the ED without being evaluated by a physician. Essentially, crowding causes a barrier for patients to access their right to emergency evaluation. The problem of crowding is most pronounced in large urban communities, and these already frequently underserved patients suffer the most from the crowding burden. The main cause of crowding seems to be the boarding of admitted patients in the ED, however many often cite high rates of non-urgent patients presenting to the ED as a cause of crowding. Some have even suggested diverting non-urgent patients to help solve the problem of crowding. I became interested in this topic due to crowding concerns and initiatives to decrease the number of patients who left without being seen at my own institution. As I reviewed relevant research, I became aware of my own misconceptions and noted a trend of literature suggesting non-urgent patients are not the cause of crowding. Drawing on research from many different sources, paired with evaluation based on principles in bioethics, I have come to several conclusions. I believe the systematic diversion of non-urgent patients is unsafe, and that the unequal burden of ED crowding on urban communities represents an unjust barrier in access to care. We must continue to carefully research the demographics of patients frequently presenting to EDs to avoid perpetuating stereotypes about which types of patients are responsible for crowding. We should also look for ways to ease the crowding burden in urban communities. Additionally, we should take a qualitative assessment of our individual communities to determine if there are any particular reasons in our community that people choose to use the ED rather than other healthcare options. I believe these suggestions can be an important addition to the efforts already in motion to help reduce ED crowding and provide equitable access to emergency medical evaluation. / Urban Bioethics