Innovations

Innovations
On a Scale of “1” to “99,” How Overloaded is Your Emergency Department?

Kern County, California earned the nickname 'California's Golden Empire,' when settlers rushed to the area in the 1800s hoping to strike it rich mining first for gold, and then for 'black gold,' or oil. The third-largest county in the state, it is still booming with a population of more than 740,000 residents that is quickly expanding. Kern County has 10 hospital emergency departments (ED), six of which are in the greater Bakersfield area.

It is one of several areas nationwide in which population growth is outpacing the expansion of ED services. Experts estimate that Kern County is approximately one to two years ahead of most areas when it comes to the rate at which growth is outpacing ED capacity, especially in the greater Bakersfield area. Consequently, county approaches to help solve the problem are monitored very closely by ED administrators nationwide.

"The greater Bakersfield area is nationally known for its peak levels of ED overload, and is periodically used as an example in the medical literature," said Russ Blind, senior EMS coordinator for Kern County. "In certain physician circles, Bakersfield's emergency medicine system has even been referred to as the Beirut of emergency department overload."

Although Kern County's EMS team has been proactively working to manage its ED overcrowding for nearly 10 years, a county-wide system introduced about five years ago has proven most successful.

"We decided to implement a managed system in which all hospitals would need to have county authorization before going on ED closure or ambulance diversion status," said Blind. "We had to get control, or a day was going to come in which all six Bakersfield area emergency departments would be on diversion, leaving patients nowhere to go."

Blind, who began his career as a paramedic and who has been on the county's EMS staff for 20 years, designed a system that calculates what is called an 'ED overload scale' for each hospital, based on readily available data. Data taken into account include the number of a hospital's ED licensed beds; the normal number of licensed nurses currently on duty, compared to the number of patients with admission orders written, but who are still waiting in the ED; the number of intensive care unit or critical care admission holds in the ED; the number of triage patients in each of the following three categories - red, yellow and green; and more.

After developing a weighted scale that would calculate the data objectively based on a hospital's size, Blind presented his system to an ED status taskforce comprised of ED physicians, nurses, and administrators, as well as EMS staff.

The new policy dictated that if a hospital ED requested closure status, the county EMS department would conduct a systematic review of all hospitals' ED overload scores to make sure it was okay.

"Before we introduced the scale, we were at the mercy of individuals' opinions about how overcrowded their EDs were," said Blind. "While the scale does not in any way solve systemic ED overload in Kern County, it does allow us to see where we truly stand on an hour-by-hour basis, subjective opinions aside."

See a hard copy of the scale

Though the ED overload score can range as high as 99 in the case of a natural disaster that sends hundreds or even thousands of individuals to EDs across the county at one time, scores are typically lower than 20. A score of one or two indicates that an ED is operating normally. A three, four or five indicates that volume in the ED is escalating, but still in the moderate range. An eight or above indicates that an ED is overcrowded, but closure status may depend on the level of crowding, or ED overload score, at other area EDs. When a hospital has a score in the 15+ range, however, its ED is significantly overcrowded and requires immediate attention.

The Kern County ED overload scale was initially tested manually by telephone query and was then later integrated into an internet-based website. The website was initially linked to greater Bakersfield hospitals before expanding to all 10 hospital EDs within Kern County. The website is now accessible to ambulance services, fire departments, dispatch centers and EMS staff. Each change in ED status or score is also message-paged to ambulance field personnel.

ED staff at each of the county's 10 hospitals are required to input their own hospital's data, usually in one- or two-hour increments. Every two hours, the program's website flashes a data update reminder screen to ensure the data tracking stays current. The county's EMS staff have found that some hospitals lag behind on their data input when things are slow, but when things pick-up, hospitals are generally quick to input data.

"Obviously, the system is based on the honesty factor, so we have to rely on the integrity of our ED staff," said Blind. "However, we do occasional spot-checks for accuracy."

This system positions Kern County on the cutting-edge of ED data technology. Blind and his team know of only one other system in the country that resembles Kern County's, but it does not incorporate as much data. For counties considering implementing a similar system, Blind cautions to keep it simple.

"Initially, we had several sub-categories that we were tracking - data pertaining to the inpatient side of things," said Blind. "We learned, however, that tracking in-house resources and folding them into the overload scale didn't make a lot of sense. We quickly discovered that the emergency department is usually a mirror of a hospital's in-house situation."

The scale system is working so well that Kern County eventually plans to provide access to area urgent care centers, physicians and managed care providers. This should help prevent individuals from being referred to a hospital ED that is already on closure and can't take any new patients. Physicians and urgent care center staff will instead have the tools they need to ensure they're sending a patient to an open and functioning ED, with the lowest ED overload score.

"Many experts point to ED overcrowding as one of the most critical challenges facing America's healthcare system. I have to believe that every large city with multiple hospitals will eventually need a system like this," said Blind. "We can't just continue subjectively saying how bad ED overcrowding is. It seems to be bad everywhere, and the causes are multi-faceted, but the question is, how bad is it really? We have to be able to measure it accurately and objectively, before we can work together to help minimize it."