Overcrowding in the Emergency Department: Could a

Patient-centred Mobile App Change This Paradigm?

Inês Margarido

, Ntumba Kasonga Alpha

, Nduami Junior

and Jan Marin

Faculty of Medicine of University of Lisbon, Portugal

Institut Supérieur d’Ingénieurs de Franche-Comté, Université de Bourgogne, Besançon, France

Biomedical Department, Ecole Centrale de Lille, Villeneuve d’Ascq, France

School of Design, Zagreb, Crotia

Keywords: Emergency Department, Overcrowding, Self-Referral.

Abstract: Overcrowding in the emergency department has been a growing worldwide problem. Some solutions have

been put forth in the several points of the patient’s path mostly in order to provide a more efficient flow of

patients within the ED. We propose, in this paper, a mobile app that could integrate real-time information of

patients, emergency departments, medical emergency teams and general practitioners. This could help scatter

the non-linear flow of patients before they arrive and ultimately improve not only quality of care but also

better patient outcomes.

1 INTRODUCTION

Emergency Department (ED) overcrowding has been

described as both a patient safety issue and a global

healthcare issue (Pines and Griffey 2015). There is

much debate as to the causes of the phenomenon,

leading to difficulties in developing successful,

targeted solutions. Approximately half of EDs all

over the world report operating near or above

maximum capacity.

Some definitions of ED overcrowding have been

put forth, but in its simplest form, overcrowding

exists when there is no space left to meet the timely

needs of the next patient requiring emergency care

(Salway et al. 2017). If the care of urgent problems is

delayed due to congestion, then overcrowding exists.

This can occur due to the volume of patients

waiting to be seen (input), delays in assessing or

treating patients already in the ED (throughput), or

impediments to patients leaving the ED once their

treatment has been completed (output) (Asplin et al.

2003).

Consequently, there are likely to be many

different causes of overcrowding, depending on when

and where in the patient journey the crowding occurs.

2 WHAT ARE THE CAUSES AND

CONSEQUENCES OF

OVERCROWDING?

2.1 Causes

In order to address this issue and provide the right

solutions, we must see at which point of the cascade

of functioning in the ED is the problem.

In the input of patients, we can point out a non-

linear presentation flow or presentations with more

urgent and complex care needs (Aboagye-Sarfo et al.

2015), increase in presentations by the elderly, high

volume of low-acuity presentations (Bond et al.

2006), limited access to primary care or diagnostic

services in community (Cowling et al. 2013).

During their time in the department, several

causes can be addressed like ED healthcare staff

shortages, presence of junior medical staff, delays in

receiving test results and delayed disposition

decisions (Van Der Linden et al. 2017).

When it comes to the output of patients some of

the reasons pointed out were the slow administrative

procedure to discharge patients and the unavailability

for admission of certain specialities in public

hospitals (Dunn 2003).

Margarido, I., Alpha, N., Junior, N. and Marin, J.

Overcrowding in the Emergency Department: Could a Patient-centred Mobile App Change This Paradigm?.

DOI: 10.5220/0009365303630367

In Proceedings of the 13th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2020) - Volume 1: BIODEVICES, pages 363-367

ISBN: 978-989-758-398-8; ISSN: 2184-4305

363

2.2 Consequences

This ED crowding leads to several consequences that

can be divided in whether patient, staff or system

related.

Effects on patients include delays in being

assessed and in receiving required care, increased

frequency of exposure to error, reduced patient

satisfaction, increased inpatient length of stay

(IPLOS) and poorer outcomes such as increased

inpatient mortality and risk of readmission (Jo et al.

2015).

When it comes to the staff, the negative effects

include increased stress and exposure to violence and

non-adherence to best practice guidelines during

times of ED overcrowding, such as increased time to

assessment of pain and/or delays in the administration

of analgesics or delayed administration of antibiotics

during ED crowding (Tsai et al. 2016).

System-level consequences identified were those

that led to `bottle-necks' in the system, namely

increases in length of stay (LOS), both within the ED

itself (EDLOS) and for those patients admitted to the

hospital (IPLOS) and ambulance diversion. Again,

these could also be viewed as consequences for

patients.

3 WHAT HAS BEEN DONE?

Several solutions have been put forward. We can also

divide these solutions according to the point of

journey in the ED.

On the issue of the input of patients some of the

studied and suggested solutions are a co-located

general practitioner (GP) in the ED (Anantharaman

2008), extended GP opening hours, choice of ED

(Sharma and Inder 2011) and social interventions

including education campaigns, financial

disincentives, redirection.

On the question of the throughput of patients there

are shown results in installing a fast-track, bedside

registration, ED nurse flow coordinator, nurse-

initiated protocols, increased ED bed numbers and

staff (Tenbensel et al. 2017), shorter turnaround-

times for laboratory tests, etc.

Solutions looking at output factors include

measurements such as active bed management

(Burley et al. 2007), leadership programs,

implementation of nationally mandated (Sullivan et

al. 2014), timed patient disposition targets, admitting

team prioritising ED admissions and increased

inpatients beds and staff.

Even if all these initiatives could be implanted,

hospitals are not immune to issues of overcrowding

and poor coordination of patient admissions,

transfers, and discharges. None of these has been

proved as the perfect solution.

4 HOW WE GOT HERE

In a systematic review (Morley et al. 2018), there was

a mismatch between proposed solutions and found

causes of ED overcrowding. Most of the solutions

presented are focused on an efficient patient flow

within the ED but a larger part of causes was

associated with the amount and type of people

attending the ED.

To tackle the problem at its origin, we believe that

a greater focus must be given to the upstream part of

the process, this meaning that our focus point are the

incoming patients. Thus, we plan on educating the

patients and reorient them towards sites capable of

hosting them depending on their need by focusing on

patients who direct themselves to the ED by personal

choice.

Indeed, and according to the Panorama des ORU,

activité des structures d’Urgence 2016, from

FEDORU (Fédération des Observatoires Régionaux

des Urgences), about 75% of the arrivals to the

emergency department were made by personal

choice. From 2015 to 2016 there was an increase of

approximately 4% in the visits to the ED. When it

comes to the hospitalizations, only 21% of them are

admitted to the hospital. The age mean of patients

going to the ED is 39 years old and only 13% of the

total of patients are more than 75 years old or less.

Another study group found that between 41.2 to

51.9% of self-referred patients in a Dutch ED visited

the ED inappropriately (Kraaijvanger et al. 2016).

4.1 Self-referrals at the ED

Taking these statistics into consideration, one must

investigate the reasons that motivate patients to visit

the ED directly, especially those with a non-urgent

condition.

A considerable number of studies has been made

in order to characterize these factors. Reasons such as

expecting investigations and wanting to see a doctor

and have tests or further research done in the same

place have been identified. The convenience of ED,

for example, convenience of access, ED nearby or the

idea that the patient could get help earlier at the ED is

also described as a major factor that influences this

kind of behaviour (Kraaijvanger et al. 2017).

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5 THE APP

We believe that in order to solve this problem of input

patients the solution that to be put forward must

combine multiple functionalities. Our approach

would put the decisions of the patient in its own

hands.

With the amount of information available online,

it’s difficult to consider only trustworthy information,

especially if one has not got a clear understanding

about the area. Therefore, there is a pressing need to

educate the population with the right knowledge in

order to prevent inappropriate trips to the ED.

By promoting health literacy, we are confident

that perhaps it could decrease the number of

unnecessary trips to the ED that end up causing

congestion on the first steps of the patient pathway

(for example the registration and triage).

Another feature of the app would be the

localization of the nearest emergency departments

and its respective waiting time. This would lead to a

more scattered flow of patients. In this way, the most

central hospitals could decrease their congestion of

ED while the outer hospitals could improve their own

flow.

There is also an urgent need to keep the

emergency medical teams updated in real-time about

the availability of the different EDs. The several ways

that patients can get to the ED must be taken into

account in order to make everything work together

through a better and faster communication with the

common purpose of redirecting correctly them to the

place where they can have the better care provided.

As we mentioned, a lot of the self-referrals on the

ED could simply be treated at a GP. This said, by

providing the availability of the local GPs we believe

that a small part of the flow could be redirected to

primary care.

6 HOW IT WORKS?

We trust that the first step to reduce the number of

non-vital patient visits in EDs, or direct them to a

primary care facility, is through a simple yet

sufficient education of the population. In this way,

they would use a device to educate themselves. The

mobile-app provides simple guidelines and

information about some medical topics that the users

can access to inform themselves about their own

pathologies, to comprehend how urgent is their

problem, if that is the case, or just to keep updated

about hot topics of the world medicine. The

guidelines used would be adapted from NICE

guidelines (National Institute of Health and Care

Excellence) or BMJ Best Practices Medicine

guidelines (British Medical Journal) for different

symptoms.

The patients will also have the possibility to check

the nearest GP and their availability with the option

to book an appointment if desired. This would be a

choice made by the patient if decides to do so.

Besides, the app would provide also the availability

and waiting times of the nearest EDs, if the patient

chooses to truly make use of the department. A map

would then be provided, and the best option of ED

will be recommended based on distance and waiting

times even though the patient can choose another one

that could be more suitable to his situation.

Figure 1: Decision making tree of the patients on our app.

By pressing the start button in the map, patient’s

data would be sent to the choosing ED and real time

updating of the arrival of patient would be done using

GPS tracking of their device. It will be, therefore,

possible to trace the patient and record their data

throughout the whole process. It is necessary to

mention that the data needed here has no other

purpose than tracing so in other words no name or

other type of personal data is needed for our goal.

During registration, already in the ED, patient’s

data will be converted and quantified to number of

patients in the ED and recorded both from the patient

using our app and those coming by their own.

These data will be redirected to emergency

medical teams in order to provide them with real-time

availability of each ED and therefore help by

improving the effectiveness and speed of reallocation

of different patients to different hospitals.

7 IMPLEMENTATION

This software is not a medical device as its intended

purpose is purely informative based on collected data

and international medical guidelines, it is not planned

Overcrowding in the Emergency Department: Could a Patient-centred Mobile App Change This Paradigm?

365

to serve as a diagnostic tool, a therapeutic tool nor a

measuring instrument.

This type of software has many features and each

of them must be clinically tested to validate the safety

of the product and to have more credibility on the

market. A clinical investigation must be done in order

to evaluate not only the effectiveness and efficiency

of the international medical guidelines contained in

the application but also the effectiveness in its

purpose of scattering the flow of the EDs.

A pilot study would have to be performed in the

form of a randomized single-blinded, control trial

with a quantitative and qualitative prospective

evaluation of the effectiveness and efficiency of the

medical guidelines contained in this software on 150

participants for 6 months. Our purpose is to evaluate

the app, if it is useful and if it promotes efficiency but

further work is needed to find the best way to evaluate

this kind of application.

8 CHALLENGES

This idea was thought out in the emergency

department with the insights of experienced doctors

and experts of the medical emergency teams, but it

lacked the patient’s point of view on this subject.

Therefore, a questionnaire or a study must be done

taking into consideration whether the patients would

be interested and make use of an app of this kind.

To make it operational and, since it is built on its

utilization by users, this mobile app must be greatly

diffused in the community, in order to reach a great

number of users. It is crucial that the dissemination of

the app is done in a rightful way.

Also, another drawback of this idea is that the app

needs to be adapted into each city, town or country

individually because the health organisation structure

could be different from one city to the other even in

the same country.

Other possible challenge would be the willingness

of the several hospitals to redirect patients to other

structures. This possibility requires a tough

negotiation with the several directions of the hospitals

of the area.

The most important challenge of this app would

be necessity to ensure that patients with a life-

threatening condition do not make the wrong

decision. Our app would only advise patients and

provide them with the necessary information for them

to make a conscious and informed decision on

whether or which ED to go to. Therefore, the question

of the responsibility of the application information

regarding the risks linked to the medical information

provided must be addressed.

9 CONCLUSIONS

It is undeniable that the problem of overcrowding

must be addressed. According to literature, there’s a

lack of solutions when it comes to the inflow of

patients therefore we strongly believe that this idea

embodies the most economical and most profitable

solution to the issue of overcrowding in the EDs, as it

gives patients the power to regulate their inflow with

the help of emergency medical teams.

We are convinced that if we give the patient the

possibility to make an informed and well-thought

choice, we could somehow manipulate the pathway

of the less-urgent patients.

ACKNOWLEDGEMENTS

This work was developed in the EIT Health ClinMed

2019 Summer School for Innovative Technologies in

Health with the support of many professionals to

whom we would like to present our most thoughtful

thanks.

To Jessica Schiro and Sylvia Pelayo from CIC-IT

Lille, who had an unwearyingly availability to answer

all our questions and guide us throughout the summer

school.

To Dr. François Dubos and Dr. Gregory Smith,

both medical doctors from the Lille Hospital, and Dr.

Facon from Lille Medical Emergency Regulation

Center (S.A.M.U) who shared with us their time and

thoughts on this problem.

Also, we would like to thank the Forum des Living

Lab en Santé et Autonomie for the opportunity to be a

part of such an amazing immersive experience.

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