Project title

The escalation procedures in crowding (EPIC) study

Country

Ireland

Background

Crowding in hospital emergency departments (EDs) increases clinical risk and can be distressing for patients. Those requiring emergency care should be treated in an environment appropriate for their clinical needs. EDs are designed to provide life- and limb-saving care, and they should not be expected to accommodate all patients awaiting a bed on a ward. To prevent compromised care, hospitals need a clear strategy for managing periods of high demand in the ED. Such plans – often called escalation policies or procedures – identify the triggers for activating the plan, the communication steps required, and the actions to be taken when there is a concern about the level of ED crowding.

Summary

As part of a coordinated response to crowded EDs in Ireland, the Health Service Executive and the Department of Health have developed an Escalation Framework in collaboration with the Irish Medical Organisation, the Irish Hospital Consultants Association and the Irish Nurses and Midwives Organisation. As part of the escalation procedure, when all other steps have been taken but crowding continues in the ED, the hospital is expected to use the Full Capacity Protocol, which involves moving appropriate patients into additional care spaces on wards or in corridors. Hospitals collect data on their escalation procedures, including the Full Capacity Protocol, which can then be used to establish the reasons they are being used across a range of Irish hospitals.

The main question as part of this research is:

Do Irish hospitals with crowded EDs use an escalation procedure, including the Full Capacity Protocol?

Subsidiary questions include:

  • In a sample of Irish acute hospitals experiencing crowding, is the nationally agreed Full Capacity Protocol employed?
  • What are the triggers to using this protocol?
  • What are the barriers to employing the Full Capacity Protocol?
  • What is the impact of employing the policy in terms of performance metrics?
  • Is there a difference in escalation procedures between hospitals with larger numbers of patients staying in the ED?
  • Is there a difference in the deployment of escalation procedures in hospitals with shorter ED lengths of stay?
  • Is there a correlation between ED length of stay for admitted patients and deployment of the escalation procedures?

The consistency with which the policy is used and the impact had will be explored in all of the hospitals involved. Reasons for crowding and barriers to the policy being used will be looked at with the senior hospital management teams and key stakeholders in each of the research hospitals.

Outcome

The EPIC study will identify what acute hospitals in Ireland do to address crowded EDs. The study will identify the key performance indicators currently being used to characterise the performance of acute hospitals in Ireland.

In phase 1 of the research, hospital performance will be assessed using data obtained from the Business Intelligence Unit of the Health Service Executive and the Irish Nurses and Midwives Organisation.

In phase 2, the qualitative element of the study will establish how much the key stakeholders in high performing and more challenged hospitals understand about the causes of crowding and the solutions to it, along with the details of their own hospital’s approach to escalation. We will be looking to identify best practice with escalation policies and to address potential barriers to them being used in a more widespread manner.