Abstract
Background
Hospital’s capacity and preparedness is one of the important parts of disaster planning.
Hospital-related incidents, a new phenomenon in Swedish healthcare, may lead to ambulance
diversions, increased waiting time at emergency departments and treatment delay along with
deterioration of disaster management and surge capacity. We aimed to identify the causes and
impacts of hospital-related incidents in Region Västra Götaland (western region of Sweden).
Methods
The regional registry at the Prehospital and Disaster Medicine Center was reviewed (2006-
2008). The number of hospital-related incidents and its causes were analyzed.
Result
There were an increasing number of hospital-related incidents mainly caused by emergency
department´s overcrowdings, the lack of beds at ordinary wards and/or intensive care units
and technical problems at the radiology departments. These incidents resulted in ambulance
diversions and reduced the prehospital capacity as well as endangering the patient safety.
Conclusion
Besides emergency department overcrowdings, ambulance diversions, endangering patient’s
safety and increasing risk for in-hospital mortality, hospital-related incidents reduces and
limits the regional preparedness by minimizing the surge capacity. In order to prevent a future
irreversible disaster, this problem should be avoided and addressed properly by further
regional studies.
Background
Region Västra Götaland is the public healthcare provider for the western part of Sweden,
with a population around 1.5 million. This task is achieved through around 150 primary
healthcare centres and 10 emergency hospitals (the largest Sahlgrenska University Hospital in
Gothenburg). PKMC (Prehospital Disaster and Medicine Centre) is a regional unit responsible
for (medical) risk assessment and emergency planning as well as staff training in disaster
management. The center is also associated with Sahlgrenska Academy in disaster research
funded by the National Board of Health and Welfare. PKMC assumes command and control
on a regional (“gold”) level in case of major incidents/disasters [1]. All incidents and
consequent activities caused by them have been registered at the centers registry (PKMC
registry) since 1999 and can be analyzed retrospectively.
The current economical crisis within most healthcare systems has resulted in local, regional
and national plans to reduce economic deficits. Most of these plans aim to increase the
healthcare systems effectiveness by reducing hospital beds and expanding out-patients
departments, which in turn challenges the mode of operation at emergency departments (ED)
[2-3]. During past decades the increasing number of patients at ED’s treatment areas has
resulted in a work overload, making EDs to operate beyond their capacity. Hospital bed
shortage enforces a rapid turnover of patients, increasing the number of patients discharged as
early as possible and endangers patient safety. Together with increasing number of non-urgent
patients these are main factors causing ED-overcrowding [1, 4-5]. To counter with
EDovercrowding escalation, new methods (e.g. triage) have been deployed, which mainly deal
with its infrastructure and internal organization [1, 6]. ED is, however, the hospital´s main
contact point with surrounding world and an important part of disaster preparedness in the
area served by the hospital. An overloaded ED has a great impact on other adjacent activities
e.g. prehospital organization, ambulance transports, elective production (surgery), and
individual patient´s safety [7-9].
During the last years a new category of incidents, “hospital-related incidents”, has appeared in
the PKMC registry. We hypothesized that these incidents are, directly or indirectly, associated
with hospital bed shortage and ED-overcrowding and consume huge regional resources. The
aim of this paper was to identify the causes of these incidents in the Region Västra Götaland
(western region of Sweden) by reviewing the PKMC registry data collected between January
1st, 2006 and December 31st, 2008.
Methods
All incoming data concerning hospital-related incidents in Region Västra Götaland , between
1st of January 2006 and 31st of December 2008, was collected. An incident was defined as an
alert from EMS (emergency medical services) dispatch centre to the regional duty officer on
call (RTiB). The RTiBs have medical background as within emergency care and special
training in management of major incidents. They have a thorough understanding of regional
resources. As a second line senior consultants (RBL) also with special training in major
incident management are available on a 24/7 basis.
Every time a contact is taken between SOS Alarm and the RTiB, data concerning this incident
and the actions that resulted are entered into a web-based registry (Saltwater TM) [10]. These
data were reviewed and analyzed for a 3-year period. The data concerning hospital-related
incidents and their impacts on that hospital´s or adjacent hospital´s ordinary activities were
extracted and evaluated. The causes of subnormal capacity at affected hospitals were then
divided into following groups; hospital bed shortage (no details specified), bed shortage at
intensive care unit, bed shortage at ordinary wards, emergency departments overcrowding and
technical dysfunction at radiology departments
Results
There were an increasing number of hospital-related incidents between 2006-01-01 and 2008-
12-31, leading to ED-overcrowding and ambulance diversions. Four incidents were registered
in 2006, of which one was due to bed shortage at intensive care units, one bed shortage at
ordinary ward and two due to technical dysfunction at a radiology department. In these
occasions ordinary patients were referred to other hospitals directly from ED, while critically
ill patients already admitted or on their way to the ED by ambulances, were transported to
other hospitals. The number of incidents has then steadily increased during 2007 and 2008,
reaching its peak at 61 incidents in 2008, which is fifteen times higher than that in 2006
(Table 1, Figure 1). During the same period, besides 61 healthcare related missions, 1046
other regional (e.g. traffic accidents, sport events), national (e.g. storm, flooding), and
international (e.g. terrorist actions, evacuation of Swedish citizens from war zones), incidents
were also entered into the PKMC registry.
Bed shortage at intensive care units could either be due to high inflow of operated patients or
high admission of critically ill patients (in need of assisted ventilation). The higher rate of
operated patients was directly related to higher number of planned operations and
simultaneous increasing in number of emergency cases. These numbers changed in 2008 to
35% and 65% for bed and respirators shortage, respectively. The lack of hospital beds at
ordinary wards was mainly due to overloaded wards. The impact on individual patients or
patients groups or the number of patients affected could not be assessed by analyzing
available data. These incidents, however, led to a total number of 350 actions undertaken by
the center. The actions undertaken were consultative, informative and supportive. However, if
necessary, the centre intervenes to coordinate and redistribute regional resources by
contacting hospitals, emergency departments, and prehospital organizations. Consequently,
unaffected patients and healthy individuals were advised to visit their general practitioners
healthcare centers or other hospitals. Current ambulance transports were diverted and planned
transports were directed to other hospitals. There was no information about the severity of
diseases in transported patients; however, critically ill patients were transported to the nearest
hospitals. The active time spent for coordinating and resolving these incidents was 21188 min
(354 hrs or 45 working days á 8h). The active reporting and writing time was 487 min.
In order to find out if hospital-related incidents are hospital-dependent, the number of
incidents per hospital was calculated. In 2006, only three hospitals in the Region Västra
Götaland, with various sizes and capacities, were involved. However the number of hospitals
reporting such incidents in the region increased during 2007 and 2008; with the highest
increase in number of incidents in the smaller hospitals. Among hospitals with 24 h
emergency departments, the smallest hospital (hospital D) was the one affected most (Table 2,
Figure 2).
Discussion
The purpose of this work was to analyze the causes of the increasing number of hospitalrelated
incidents in Region Västra Götaland of Sweden and their impacts on the prehospital
and hospital preparedness in case of major incidents. In our study the alert is initiated by the
affected ED requesting the EMS dispatch centre to divert patients transported by ambulance
to other EDs. One limitation to this study is the lack of possibility to measure the impact of
ambulance diversions on individual patients or patients groups. The main cause of hospital related incidents in this report was labeled as ED-overcrowding. There is however no
universal definition for ED-overcrowding, as each hospital might have its own definition.
Disasters seldom occur, but if they strike a fast and effective response from healthcare
services is expected. An increasing number of reports on incidents when emergency hospitals,
for different reasons, cannot operate at their normal capacity are a matter of concern for
patient safety as well as disaster response preparedness [7]. In the available literature hospital
bed shortage and ED downsizing are reported to be some of the causes of ED-overcrowding
leading to impaired responsiveness and ambulance diversions [4, 6, 8-9, 11-12]. In our study,
we could also show that hospital bed shortage and technical dysfunction at radiology
departments, beside the increasing number of patients at EDs are the main reasons for EDovercrowding in our region. Our findings (Table 1, Figure 1) are consistent with those earlier
reported. Like in many other parts of the world, reduction of hospital beds and corresponding
staff in combination with increasing number of out-patients treatments and coordination of
activities between nearly located hospitals, have been some of the solutions to handle the
economical constrain on the healthcare systems [9, 11, 13]. The mean length of hospital stay
(LOS) has been reduced in Sweden, as well as other Scandinavian countries, having the
lowest LOS worldwide [5, 14]. Although these measures all seem to be logical steps taken to improve healthcare effectiveness and reducing the costs, they also, in a negative way, affect
the surge capacity of a hospital. Such capacity in hospitals is necessary for proper
management of extraordinary incidents and is influenced by 3 essential elements; staff,
supplies/equipment, and structure [15-16]. Structure refers to both location for patients and
the organizational infrastructure. A key to a successful major incidents response of a hospital
is an ED that is able to effectively sort (triage) the casualties, continue or start lifesaving
treatment and rapidly transfer patients to facilities for definitive treatment within the hospital.
If this key function is overcrowded already at the onset of a disaster response, the outcome for
the patients will be suboptimal. It is already reported that ED-overcrowding is associated with
both space and staff shortage [4, 7, 17-18].
Hospital bed occupancy of > 90% has been shown to correlate with a blocked access to the
wards, defined as patients waiting in the ED for more than 8 h when the decision has been
made to admit them [4, 19-21]. For severely ill patients this consequently leads to initiation of
extra measures e.g. multiple testing, interventions and administration of drugs during their
prolonged stay in the ED [4, 7, 19-20]. In such situations the ED serves as a holding area for
admitted patients, sometimes remaining for more than 24 h, due to the lack of beds [4]. This
even includes patients in need of beds at the intensive care units. Earlier reports indicate that
the average waiting time for an inpatient acute or critical care bed in the USA EDs has nearly
been doubled (> 6 h) in hospital with consistently overcrowded ED. The results, besides
missed diagnoses, poor outcomes, prolonged pain and suffering for some patients, long
waiting times, patient dissatisfaction, more ambulance diversions, lower physician and staff
productivity and higher levels of frustration among medical staff, are higher hospital costs and
longer LOS [2, 11-13, 21].
In addition many patients in the early time period of their diseases may leave ED due to long
waiting time, without treatment. Curable disease may then become more critical and incurable
when they return [4]. Delay of > 6 h in bringing ED patients in critical condition to intensive
care unit has also shown to increase hospital LOS and result in higher intensive care unit and
hospital mortality [20].
Long-lasting hospital closure are associated with significant but temporary increase in
ambulance diversions to the nearest ED. Fewer EDs and increasing number of patient visits
over time, may also cause ED-overcrowding and consequent ambulance diversions [9, 22].
Ambulance diversion has a huge impact on public health, since it may place the patient at risk
for poor outcome, prolonged pain and suffering. Ambulance diversion results in increasing
transport time between hospitals, delayed treatments and may also increase mortality in
severely injured trauma patients [7, 9, 22]. It also results in significant loss of hospital revenue
due to the throughput delays that prevent the use of existing bed capacity for additional
patient admissions [23]
In conclusion hospital-related incidents are by no means extraordinary incidents, but part of
the ordinary shortcoming of the healthcare system caused, among others, by reduction in
number of hospital beds, downsizing and/or closure of hospitals EDs. Such measures results
in overcrowding of EDs and ambulance diversions. They also endanger patient´s safety and
may increase in-hospital mortality. It counteracts medical preparedness by minimizing the
surge capacity. In the context of disaster preparedness this problem must be further studied
and properly addressed by our political decision makers (24)
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Source : http://www.sjtrem.com/content/pdf/1757-7241-17-26.pdf
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