Abstract of Dissertation

Keyword : Access Block, Boarding of Patients, Accident and Emergency Department, Length of Stay, Hospital Outcome, Delay in Admission

Objective : To investigate the relationship between access block in the emergency department (ED) (defined as total time from arrival to transfer from the ED over eight hours) and inpatient length of stay (LOS).

Background : Accident and emergency department (A&E) provides access to hospital services for urgent cases and 15-20% of patients arriving in A&E require admission to in patient wards but admission through the A&E accounts for a sizable portion of all admissions to surgery and inpatient wards. The spectacle of sick people whose condition merited admission as inpatients waiting overnight on trolleys, or even being treated in ambulances parked outside the unit has provoked widespread criticism. Access block” refers to the situation where patients requiring emergency hospital admission spend an unreasonable amount of time in an emergency department (ED) because they are unable to gain access to appropriate hospital inpatient beds. It is the proportion of A&E patients requiring admission whose total time within the A&E exceeds 8 hours. It is linked to increase A&E waiting time for medical care and leads to A&E overcrowding. This overcrowding is generally accepted to decrease efficiency and possibly quality of care and may impact hospital outcomes such as length of stay.

Methodology : Retrospective cohort study of all admissions through the ED to inpatient unit in a tertiary hospital in USA, during September 2014 till March 2015.Total time in the ED calculated in hours and LOS calculated in days from ED departure to hospital discharge.

Findings : 3535 admissions were included, and 911 experienced access block (25%). Mean LOS was 6 days 9 hours and mean ED LOS was 6 hours. Mean LOS in those who experienced access block was 7 days (95% CI, 7.28-6.72), compared with 6 days in the no-block group (95% CI, 6.49–5.51; P < 0.0005). Subgroup analysis showed that this “access block effect” occurred across different severities of illness and age groups Among patients admitted to the hospital from the ED, patients with ED LOS > 8 hours are associated with 16% longer IP LOS. The cumulative effect of delay on the 911 patients who experienced delay was an additional 1,176 hospital days. The major delay is likely due to the unavailability of vacant bed but further studies need to be conducted to find root cause of this delay and interventions need to be carried out that will improve ED flow and reduce admission delay.