Correspondence

Regarding the adjustment of roster according to ED census

To the Editor,

I have read the interesting proposal of Ong et al [1] of emergency department (ED) physicians’ roster adjustment according to daytime, weekday, and seasonal fluctuations of ED necessities, basically estimated by the total number of ED attendances. The aim of the study is to face ED overcrowding, a major ED worldwide blight [2-4], by matching ED staffing and resources to actual conditions. I have no doubt regarding the robustness of the methodology used for achieving their final model. However, I believe that this is a path that ED physicians should not undertake. For more than 10 years, I have studied the behavior of an ED located in an urban tertiary-care hospital in Barcelona (Catalonia, Spain), as well as the patient flow across it [5-7]. All in all, I have reached the certainty that, in nearly all cases, the main responsibility of such overcrowding lies not in the ED staff insufficiency or even in the inadequacy of duty strategies to match ED manpower with ED necessities but it essentially depends on the lack of physical space in the ED, excessive boarding of patients, limitation of in-Hospital beds for patients needing to be admitted, and/or the feeling (overt or hidden) of hospital administrators and politicians that the ED is a “high-risk area” where “the best news is no news.”

In this scenario, it is not reasonable to force physicians to

adjust their duties (and their life) to the capricious patient demand of urgent care. It would imply a lot of different shifts and, eventually, the necessity of splitting the labor day. The ED census, as Ong et al demonstrates, is more predictable rather than random [6,8]. Accordingly, Hospital resources (and not ED physicians) should move around it. It is well known that internal factors (hospital and structural ED organization) are more influent than external factors (ED census) in ED performance [9,10]. Only after the correction of all these modifiable causes of Patient throughput and output delay could roster adjustment to patient census make sense. Obviously, I would wish that the

strategy of Ong et al achieve success, but I am reluctant. Unfortunately, the volatility of strategies intended to improve ED patient flow has proven to be a general rule [7]. I will be looking for their future (hopefully positive) results.

Oscar Miro MD

Emergency Department Hospital Clinic, 08036 Barcelona

Catalonia, Spain E-mail address: [email protected]

doi:10.1016/j.ajem.2009.01.007

References

1. Ong ME, Ho KK, Tan TP, Koh SK, Almuthar Z, Overton J, et al. Using demand analysis and system status management for predicting ED attendances and rostering. Am J Emerg Med 2009;27:16-22.
2. Derlet RW, Richards JR. Overcrowding in the nation’s emergency departments: complex causes and disturbing effects. Ann Emerg Med 2000;35(1):63-8.
3. Moreno Millan E. Servicios de urgencias y listas de espera [in Spanish].

Emergencias 2007;19:57-8.

1. Sanchez M, Salgado E, Miro O. Mecanismos organizativos de adaptacion y supervivencia de los servicios de urgencia [in Spanish]. Emergencias 2008;20:48-53.
2. Miro O, Antonio MT, Jimenez S, De Dios A, Sanchez M, Borras A, et al. Decreased health care quality associated with emergency department overcrowding. Eur J Emerg Med 1999;6:105-7.
3. Miro O, Sanchez M, Espinosa G, Coll-Vinent B, Bragulat E, Milla

J. Analysis of patient flow in the emergency department and the effect of an extensive reorganisation. Emerg Med J 2003;20:143-8.

1. Miro O, Salgado E, Sanchez M. Why are strategies for improving ED effectiveness so volatile? J Emerg Med 2009 [in press].
2. Sanchez M, Smally AJ. Comportamiento de un servicio de urgencias segun el dia de la semana y el numero de visitas [in Spanish]. Emergencias 2007;19:319-22.
3. Espinosa G, Miro O, Sanchez M, Coll-Vinent B, Milla J. Effects of external and internal factors on emergency department overcrowding. Ann Emerg Med 2002;39:693-5.
4. Moreno Millan E, Garcia Torrecillas JM, Lea Pereira MC. Diferencias de gestion entre los ingresos urgentes y los programados en funcion de los grupos relacionados de diagnostico y la edad de los pacientes [in Spanish]. Emergencias 2007;19:122-8.

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