Introduction: Access block (AB) is the most important indicator of Emergency Department (ED) crowding, but the impact of AB on consultation time has not been described. Our objectives were to determine if ED AB affects inpatient service consultation time, and operational and patient outcomes. Methods: We conducted a health records review of all ED patients referred and admitted at a university-affiliated tertiary care hospital over 60-days. A computational algorithm determined hourly ED AB at the time of consultation request, and observational cohorts were determined based on ED AB high (>35% ED bed capacity occupied by admitted patients) or low (<35%). The outcomes included total consultation time (TCT), ED physician initial assessment (PIA) time, ED length of stay (LOS), transfer time to inpatient bed (TTB), hospital LOS, return to ED (RTED) within 30 days, and 30-day mortality. Results: We included 2,871 patients (48% male; M = 63 years, IQR 45–78), and the low AB cohort were higher acuity (N = 1,692; 50.4% CTAS 1–2) than the high AB cohort (N = 1,179; 47.1% CTAS 1–2). Median TCT was not significantly different (low = 209min, high = 212min; p = 0.09), and there was no difference in consults completed within the 3-hour institutional time target (low = 41.1%, high = 40.9%; p = 0.89). Median ED PIA time was not significantly different (low = 66min, high = 68min; p = 0.08), however, patients seen within the funding-associated provincial ED PIA time target was significantly less during high AB (high = 82.2%, low = 89.2%; p < 0.001). Median ED LOS was significantly longer during high AB (high = 12.1hr, low = 11.1hr; p = 0.009), but median hospital LOS was not different (high = 109.5hr, low = 112.4hr; p = 0.44). Median TTB was significantly longer during high AB (high = 8.0hr, low = 5.9hr; p = 0.0004). There was no difference in RTED visits (high = 12.4%, low = 10.6%; p = 0.15) or 30-day mortality (high = 8.4%, low = 9.2%; p = 0.51). Conclusion: In conclusion, consultation time is not affected by AB. However, boarding admitted patients in the ED impairs our ability to meet funding-associated performance metrics. Reducing boarding time should be an ED and hospital-wide priority, as it negatively impacts funding and delays patient care.

Introduction: Extended length of stay (LOS) in emergency departments (EDs) and overcrowding are a problems for the Canadian healthcare system, which can lead to the creation of a healthcare access block, a reduced health outcome for acute care patients, and decreased satisfaction with the health care system. The goal of this study is to identify and assess specific factors that predict length of stay in EDs for those patients who fall in the highest LOS category. Methods: A total of 130 patient charts from EDs in Regina were reviewed. Charts included in this study were from the 90th-100th percentile of time-users, who were registered during February 2016, and were admitted to hospital from the ED. Patient demographic data and ED visit data were collected. T-tests and multiple regression analyses were conducted to identify any significant predictors of our outcome variable, LOS. Results: None of the demographic variables showed a significant relationship with LOS (age: p=.36; sex: p=.92, CTAS: p=.48), nor did most of the included ED visit data such as door to doctor time (p=.34) and time for imaging studies (X-ray: p=.56; ultrasound: p=.50; CT p=.45). However, the time between the request for consult until the decision to admit did show a significant relationship with LOS (p<.01).Potential confounding variables analyzed were social work consult requests (p=.14), number of emergency visits on day of registration (p=.62), and hour of registration (00-12 or 12-24-p<.01). After adjustment for time of registration, using hierarchical multiple regression, time from consult request to admit decision maintained a significant predictor (p<.01) of LOS. Conclusion: After adjusting for the influence of confounding factors, “consult request to admit decision” was by far the strongest predictor of LOS of all included variables in our study. The results of this study were limited to some extent by inconsistencies in the documentation of some of the analyzed metrics. Establishing standardized documentation could reduce this issue in future studies of this nature. Future areas of interest include establishing a standard reference for our variables, a further analysis into why consult requests are a major predictor, and how to alleviate this in the future.

Introduction: Emergency department (ED) access block is the #1 safety concern in Canadian EDs. Its main cause is hospital access block, manifested by prolonged boarding of inpatients in EDs. Hospital administrators often believe this problem is too big to be solved and would require large increases in hospital capacity. Our objective was to quantify ED access gap by estimating the cumulative hours that CTAS 1-3 patients are blocked in waiting areas. This value, expressed as a proportion of inpatient care capacity, is an estimate of the bed hours a hospital would have to find in order to resolve ED access. Methods: A convenience sample of urban Canadian ED directors were asked to provide data summarizing their CTAS 1-3 inflow, the proportion triaged to nursed stretchers vs. RAZ or Intake areas, and time to care space. Total ED access gap was calculated by multiplying the number of CTAS 1-3 patients by their average delay to care space. Time to stretcher was captured electronically at participating sites, but time to RAZ or intake spaces was often not. In such cases, respondents provided time from triage to first RN or MD assessment in these areas. The primary outcome was total annual ED access block hours for emergent-urgent patients, expressed as a proportion of funded inpatient bed hours. Results: Directors of 40 EDs were queried. Six sites did not gather the data elements required. Of 34 remaining, 29 (85.3%) provided data, including 15 tertiary (T), 10 community (C) and 2 pediatric (P) sites in 12 cities. Mean census for the 3 ED types was 72,308 (T), 58,849 C) and 61,050 (P) visits per year. CTAS 1-3 patients accounted for 73.4% (T), 67.7% (C) and 66.2% (P) of visits in the 3 groups, and 34% (T), 46% (C) and 44% (P) of these patients were treated in RAZ or intake areas rather than staffed ED stretchers. Mean time to stretcher/RAZ care was 50/71 min (T), 46/62 min (C), and 37/59 min (P). Average ED access gap was 47,564 hrs (T), 37,222 hrs (C) and 35,407 hrs (P), while average inpatient bed capacity was 599 beds (5,243,486 hrs), 291 beds (2,545,875 hrs) and 150 beds (1,314,000 hrs) respectively. ED access gap as a proportion of inpatient care capacity was 0.93% for tertiary, 1.46% for community and 2.69% for pediatric centres. Conclusion: ED access gap is very large in Canadian EDs, but small compared to hospital operating capacity. Hospital capacity or efficiency improvements in the range of 1-3% could profoundly mitigate ED access block.