How Do You Deal with Overcrowding in Your ED ? - Taiwan's Experience
1Emergency Department, National Taiwan University Hospital, Taiwan
Overcrowding in emergency departments (EDs) is a globally concerned issue. The causes and possible solutions for ED overcrowding would vary largely in different health care systems. The National Health Insurance in Taiwan is famous for health care quality and cost-effectiveness, but is still far from perfect. On average, 1 out of 3 people in Taiwan will have an ED visit in one year. People are free to choose any primary care clinic, ED or hospital at a relatively low cost. Diagnosis-related group programs are not widely implemented and the reimbursement is primarily based on fee-for-service. ED overcrowding occurs generally in about 10 major medical centers in Taiwan. The waiting times in the EDs are relatively short and the major cause of overcrowding in Taiwan comes from too many admitted patients boarding in the ED hallways. Elderly male patients with higher triage levels and more comorbidities are more likely to stay longer in the EDs and contribute more to overcrowding. As people are aging, the demand for high quality medical care far outweighs supplies years by years. The strategies for dealing with ED overcrowding in Taiwan will be structured in 3 parts: input, throughput, and output.
Higher copayments for emergency triage levels 3 to 5 in medical centers, providing crowding information of EDs via mobile phone apps, and moralist propaganda were some actions trying to divert patients away from overcrowded EDs. However, the effects are just next to nothing.
A universal five-level triage system and healthcare technologies, such as sonography, clinical pathways, and decision aids, are available now or in the near future in Taiwan EDs to improve efficiency during throughput process. Increased staffing with nursing practitioners and clinical assistants can also serve to reduce overcrowding and waiting times.
Increasing turnover rate of hospital beds and rate of hospital admissions from the ED are two very effective strategies to decrease ED boarding patients but also have constraints from hospital policies. Active inter-facility transfer of ED boarding patients in the overcrowded EDs to local hospitals is a new strategy to alleviate the problem of overcrowding in Taipei, Taiwan. On average, the monthly transfer patients increased by 8 times. Compared to the numbers of ED boarding patients in the medical centers, the effect is small but encouraging.
ED overcrowding is a system-based problem and beyond the capacity of individual hospitals to solve alone. A multifaceted approach involving health care system reform would be possible to solve the problem of ED overcrowding fundamentally.