Crowding in the emergency department is a global concern. Crowding increases mortality and decreases the quality of care given to patients. Crowding also has widespread implications for the wellbeing of staff with a decrease in job satisfaction, and an increase in burnout and moral distress. To date, research on crowding has focussed on staff experience and systemic failures and inefficiencies. Little is known about the patient experience during crowding and is limited to analyses of service outcomes. Patient experience in the emergency department is key to the overall satisfaction for the patient and their family and healthcare professionals. To date there has been a gap in the literature on the psychological, emotional and experiential experience of patients who are sitting in crowded emergency department. This week we have a really interesting study that explores the patient experience of the ED. The abstract is below, but as always we recommend you read the full paper yourself. This is especially important to read the quotes from participants which provide a real depth of understanding of their experience.
What kind of study is this?
This is a qualitative study, using semi-structured interviews underpinned by the theory of interpretative phenomenological analysis. For those who may not be familiar with this methodology it aims to capture the ‘essence of experience’ for people in the moment. This rich data is not something easily captured in quantitative methodologies or surveys. The methodology focuses on the participants narrative and insights, targeting the essence of the persons experience rather than having a goal of generalisability. As a qualitative researcher I can guarantee that when it is done well qualitative research is extremely labour intensive, time consuming and rigorous. If you remain sceptical, I encourage you to read on to hear what these patients and their families had to say about their experience of crowding. The aim of this study was to learn specifically about patient and carers experience of crowding rather than wait times.
Defining ‘crowding’
I think we all know what crowding feels like, but in research definitions are important and here crowding was defined as occupancy >75% bedspace occupancy, ambulance handover times >30 minutes and transfer to the ward times >60 minutes. During the recruitment of participants for this study, the ED was at >100% occupancy with ward transfers >12 hours.
How did they collect data?
Patients were asked to participate in a semi-structured interview with a single researcher while they were actively waiting for their care in the ED, at a time that was not disruptive to care. Interviews occurred while in the ED for the current presentation, in real time while experiencing ‘crowding’. The interviews were conducted across the 24/7 shifts, including nights and weekends, when there was crowding. The interviews were conducted in a private space while waiting for interventions, investigations or for transfers. The interviews were conducted by a mid-career emergency physician with a PhD in qualitative research methodologies and three senior medical students. Following an emergency care literature search a topic guide was developed to inform the questions to be asked.
Tell me about the participants.
Only adult patients and the people who accompanied them were recruited. The study was conducted in a large, busy UK ED (approximately 200 chairs) with a catchment population of 1.4million people. Adults who had conversational English, were not prisoners and did not require immediate medical attention were eligible to participate. Participants had to have capacity to consent. This was a purposive sample with patients being approached to represent the wide demographics of the patient population of this ED, targeting diversity of age, acuity, frailty, ethnicity and wait times.
How did they analyse the data?
Interviews were recorded, anonymised and transcribed verbatim. Analysis had two objectives. First, to understand than describe the meaningful context of ED crowding through the experience of participants. Secondly, to formulate recommendations for mitigating interventions from both the participants experiences and their own suggestios
Authors read each of the transcripts a minimum of twice and organised the data using open codes to discuss the experience and potential intervention. Interpretative phenomenological analysis was utilised, data immersion, note-making and formulation of emergent themes and synthesising the findings. Codes and corresponding quotes were tabulated using a macro script. The interviewers then met twice to generate common themes and experiences.
What are the main findings/results?
Ten people in total participated in the study. They were aged between 24-87 years. Seven patients and three partners. Participants were recruited from the adult triage (2), adult ambulatory majors (3) and the adult ambulance assessment temporary overflow structure (2). Wait times were between 30 minutes and 13 hours, with an average wait time of 3 hours 20 minutes.
Three main themes of the experience of crowding came from the data: 1). loss of autonomy, 2). unmet expectations and 3). vulnerability.
The main experience of crowding in the ED for participants was one of a negative healthcare experience.
Loss of Autonomy
Participants were resigned to the fact that crowding was part of the ED process and there were no alternatives, so they had to tolerate the situation. Although the participants could see the level of activity in the ED, they reported feeling unable to even approach the staff for assistance because they considered the staff to be too busy. Participants reported uncertainty around ED process and timing and treatments making it difficult to understand what to organise for travel or what needed to be organised for young children at home. Interestingly, participants suggested interventions to reduce certainty and alleviate their loss of autonomy, this included a rolling display showing realistic wait times and staff wearing uniforms to demonstrate their discipline.
Unmet Expectations
The data was collected following COVID-19 restrictions however participants remained concerned that the crowded environment posed danger to their health. A lack of space and a lack of facilities also impacted on the opportunity for participants to access food and meant poor personal hygiene. Despite the crowding, participants who attended alone, still felt lonely and tried to distract themselves by contacting relatives. Unmet expectations led participants expressing a reluctance to attend again in the future. Participants proposed several interventions such as appropriate signage to aid in accessing the toilets and water a television for distraction. Worryingly some patients really did not want to return to the ED unless on the verge of death.
Vulnerability
Participants made suggestions to improve efficiency and clarity of process out of concerns for other patients. Better signage was a key suggestion
What can we take away from this study?
Crowding negatively impacted the patient and their carers experience of the ED. Loss of autonomy, unmet expectations vulnerability where the three major findings. Crowding has been previously associated with negative experiences for the patient and carers with reports of poor communication and responses, missed and delayed treatments. This study identified frustration and depersonalisation by the participants.
That said there are lots of useful suggestions in the paper, some of which I’ve outlined below.
• Having clear signage for approximate wait times would allow patients and their families to make decisions about needs while in the ED and for the broader family system.
• An estimation of wait times may discourage people with minor concerns who could wait for the GP may then choose not to wait.
• Having clear signage to find toilets and water and stating whether food will or will not be available, and where food is available would be useful.
• Boredom, loneliness and vulnerability may all contribute to complaints, or in extreme situations occupation violence. Advocating for a TV, an aquarium, power sockets to charge phones may all help to mitigate this risk.
• Most patients do not understand hospital systems and cannot imagine processes so clearly stating what is happening next, how it will happen would be useful. For example, “ok Mr X, you will need an x-ray before we can tell you what is going on. X-ray is quite busy so this may take several hours. Here is some pain relief. Please let us know if the pain gets worse”.
• Being mindful that patients who attend alone may be frightened and feeling vulnerable and how a small, compassionate exchange may assist in offering reassurance.
• Patients spoke of their hesitation to request assistance because they are concerned for the wellbeing of staff is not uncommon. This may increase risk if patients do not escalate increasing pain or illness. Stating to the very ill, please do hit the buzzer or let us know if things change is important.
What are the limitations of this study?
The authors correctly identified several limitations to the study. The study sought internal validity for local interventions resulting in an inability to generalise to wider ED departments, though transferability remains possible. The ED in the study had specific environmental factors (floorplans) that contributed to a disproportionate sense of crowding.
The targeted sampling of the population dependent on the researcher’s availability and crowding which may have created a selection bias for people more confident and feeling more well to participate.
The authors should have acknowledged a greater risk of the power imbalance for patients waiting to be seen and their potential concerns for not participating or unspoken hopes that participating would influence wait times irrespective of what was said. Recognising the intention of the methodology, seven patients is a small representation of patient experience
Final thoughts
There are many barriers to capturing the patient experience in the ED department. This study is novel and warrants consideration. Remembering that our patients are powerless and frightened is important to remember whatever our level of interaction. An extra minute offering reassurance and realistic timeframes may change the patients narrative of the ED experience and ensure they are kept safe in our care.
Liz Crowe
Dr Liz Crowe Wellbeing Consultant, Executive Coach, Wellbeing and Social Science Researcher, Loss and Grief expert, Advocate of Clinical Debriefing.
Co-host Five Things Nursing Podcast LizCrowe.org
References and further reading
- Craston AIP, Scott-Murfitt H, Omar MT, et al Being a patient in a crowded emergency department: a qualitative service evaluation. Emergency Medicine Journal Published Online First: 30 July 2024. doi: 10.1136/emermed-2023-213751
- Gregory Yates, “Are long waits in A&E lethal for elderly patients?,” in St.Emlyn’s, March 11, 2024, https://www.stemlynsblog.org/elderly-mortality/.
- Stevan Bruijns, “JC: To batch or not to batch? Managing flow in the ED,” in St.Emlyn’s, October 1, 2022, https://www.stemlynsblog.org/jc-to-batch-or-not-to-batch-managing-flow-in-the-ed/.
- Simon Carley, “Studying for FCM (Fellow of Corridor Medicine) at St.Emlyn’s,” in St.Emlyn’s, December 19, 2014, https://www.stemlynsblog.org/studying-fcm-fellow-corridor-medicine-st-emlyns/.
Great summary.
The crowding definition the less than ().