“The kind of day when your patient flow managers have waved the white flag’’ – does this sound familiar? ED crowding is endemic in the UK (and elsewhere in the world) and very dangerous for patients. Even patients you think are OK to go home are more likely to die if there are long waits in the ED (!) and RCEM estimates that a department seeing 50k patients/year will see 13 extra deaths each year due to crowding.

Why does it occur?

We have known for years that the causes and effective solutions to ED crowding lie outside the ED, and Adrian emphasised the key points to hammer home to your management:

  • Win the argument that crowding is not “just a busy day”
  • Challenge the myth that this is about “inappropriate attenders” – it is not
  • Emphasise that the most effective solutions lie outside the ED
  • Think of solutions for Input/Throughput/Output

Adrian emphasised some of the key evidence-base about ED crowding. Firstly, it doesn’t usually occur in all parts of the ED at the same time – your resus room may be overflowing whilst minors or paeds is OK. Secondly, ED crowding is usually a reflection of a crowded emergency care system. And thirdly, the link between hospital capacity (or, I assume, lack of!) is overwhelming.

What to do when it happens

So how did Adrian recommend we actually manage a crowded ED? Think of the principles used for major incident management – “you must have hands off roles”.

If you’re in charge, you need to maintain situational awareness and not get sucked into the hands-on care of individual patients – think “Bronze Command”. Some EDs call this the “Fat Controller” role, others EPIC (Emergency Physicians in Charge) – in ours, it’s the Shop Floor Supervisor (or “Head Chef”) ! You also need a Nurse Controller. And you need to escalate and delegate in order not to get caught up doing hands-on tasks whilst trying to manage the situation.

This is all such an important skill for today’s Emergency Physicians we now have an assessment tool to help trainees develop it – the Extended Situational Learning Event or ESLE.

As for tasking your team, did you know those tricks that we’ve all learned to do when it’s gone belly up – blitzing minors, or making sure that senior docs concentrate on the potential discharges leaving obvious admissions to the juniors? They’ve all got names!

Never waste a good crisis!

It’s no good going to your managers and shouting at them that your ED is overflowing and dangerous. Have some specifics up your sleeve to ask for:

  • Ask for improvements in the co-ordination of available capacity (e.g. early discharges, discharge lounges, and weekend discharges).
  • Ask for a hospital-wide Full Capacity Protocol
  • Ask for boarding (i.e. sending patients to wards before their identified bed is ready)
  • Ask how they’ll enforce this (Board to Ward)

Overall, a very useful talk from a subject matter expert who has to fight the same battles as the rest of us when facing crowding problems in our departments.