Implementation of crowding solutions from the American College of Emergency Physicians Task Force report on boarding

Study Objective: We sought to measure the self-reported implementation of the crowding solutions outlined in the 2008 American College of Emergency Physicians (ACEP) Boarding Task Force report "Emergency Department Crowding: High-Impact Solutions." We also tested the hypothesis that the self-reported crowding of emergency departments (EDs) was positively associated with the implementation of these solutions. Methods: In early 2009, we mailed a survey to all medical or nursing directors from EDs in four US states asking for information regarding their EDs in 2008. Geographic information about the EDs was included in the analysis, along with survey responses about their ED capacity status and implementation of specific ACEP crowding solutions. Results: A total of 284 of 351 EDs responded (81%). The majority of EDs were in urban areas (56%), non-teaching hospitals (93%), and not critical access hospitals (76%). The percentage of EDs "over capacity" ranged from 10-49% in each state. The mean number of crowding solutions used in EDs that were at or over capacity ranged from 3.6-4.6 in each state. EDs with visit volumes greater than or equal to three patients/hour were more likely to be over capacity than at capacity or at a good balance (46% vs. 31% and 15%, respectively). In terms of the use of high-impact crowding solutions, hospitals over capacity were more likely to utilize inpatient full capacity protocols (40% vs. 25% and 25%) but not inpatient discharge coordination (29% vs. 27% and 34%) or surgical schedule smoothing (31% vs. 28% and 32%). Hospitals over capacity were also more likely to have fast track units (44% vs. 32% and 16%) and physicians at triage (48% vs. 29% and 17%). Conclusion: Less than half of EDs in each state reported operation above capacity. Implementation of some crowding solutions was more common in the above-capacity EDs, although these solutions were not consistently used across geographic locations and hospitals. Given that the majority of EDs were not over capacity, the implementation of these solutions does not seem to be universally necessary.