American Journal of Emergency Medicine (2012) 30, 412-420

Original Contribution

The role of full capacity protocols on mitigating overcrowding in EDs^?,??

Cristina Villa-Roel MD ^a,b, Xiaoyan Guo ^a, Brian R. Holroyd MD ^a, Grant Innes MD ^c, Lyndsey Wong MD ^d, Maria Ospina ^b,e, Michael Schull MD ^f, Benjamin Vandermeer ^g,

Michael J. Bullard MD ^a, Brian H. Rowe MD ^a,b,g,?

^aDepartment of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada T6G 2B7 ^bSchool of Public Health, University of Alberta, Edmonton, Alberta, Canada T6G 2T4 ^cDepartment of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada T3B 2B9 ^dUniversity of British Columbia, Rural Family Medicine Program, Kelowna, BC, Canada V1Y 1T3 ^eInstitute of Health Economics, Edmonton, Alberta, Canada T5J 3N4

^fDepartment of Medicine (Division of Emergency Medicine), University of Toronto, Toronto, Ontario, Canada M4N 3M5

^gUniversity of Alberta/Alberta Health Services evidence-based practice Centre, Edmonton, Alberta, Canada T6G 2J3

Received 15 September 2010; revised 26 November 2010; accepted 29 December 2010

Abstract

Objective: Overcrowding is an important issue facing many emergency departments (EDs). access block (admitted patients occupying ED stretchers) is a leading contributor, and expeditious placement of admitted patients is an area of research interest. This review examined the effectiveness of full capacity protocols (FCPs) on mitigating ED overcrowding.

Methods: A Comprehensive literature search was undertaken to identify potentially relevant studies between 1966 and 2009. Intervention studies in which an FCP was used to influence ED/hospital length of stay and ED/hospital access block were included as a single program or part of a systemwide intervention. Two reviewers independently assessed citation relevance, inclusion, study quality, and extracted data; because of limited data, pooling was not undertaken.

Results: From 14 446 potentially relevant studies, 2 abstracts from the same comparative study were included. From 29 studies on systemwide intervention, 4 contained an FCP component. The included study was a single-center ED study using a before-after design; its methodological quality was rated as weak. One of the abstracts reported that an FCP was associated with less ED length of stay (5-hour reduction) when compared with the comparison period; the other reported that an FCP decreased ED

^? Data from this study were presented at the following scientific meeting: Canadian Association of Emergency Physicians Annual Scientific Meeting, Montreal, Quebec, Canada, May 29-June 2, 2010.

^?? Funding: This study was funded by a grant from the Canadian Institutes for Health Research (CIHR; 200810KRS). Dr Schull is supported by the CIHR

as an Applied Chair in Health Services and Policy Research (Ottawa, Ontario). Dr Villa-Roel is supported by CIHR in partnership with the Knowledge Translation branch. Dr Rowe is supported by the 21st Century Canada Research Chairs program through the Government of Canada (Ottawa, Ontario).

* Corresponding author at: Department of Emergency Medicine, University of Alberta, 1G1.42 Walter C. Mackenzie Centre, Edmonton, Alberta, Canada

T6G 2B7. Tel.: +1 780 407 6707; fax: +1 780 407 3982.

E-mail address: [email protected] (B.H. Rowe).

0735-6757/$ – see front matter (C) 2012 doi:10.1016/j.ajem.2010.12.035

and hospital access block (28% and 37% reduction, respectively). The ED triggers, format, and implementation of FCP protocols varied widely.

Conclusion: Although FCPs may be a promising alternative for overcrowded EDs, the available evidence upon which to support implementation of an FCP is limited. Additional efforts are required to improve the outcome reporting of FCP research using high-quality research methods.

(C) 2012

Introduction

Emergency department (ED) overcrowding is a serious concern for hospitals in many developed countries [1]. The consequences of ED overcrowding include delays in time- sensitive diagnostic and Treatment decisions, patients leaving without completion of care, patient and provider dissatisfac- tion, as well as poor outcomes [1,2]. The cause of ED overcrowding is multifactorial; however, it is generally considered to be a combination of input, throughput, and output factors [1,3]. Emergency department overcrowding is further classified as a systemwide problem. For example, inpatient overcapacity leads to admitted patients being kept in the ED; and lack of ED care spaces leads to Ambulance diversion and delayed off-loading. Not surprisingly, efforts to mitigate ED overcrowding have focused on input, throughput, and output interventions, often bundled in a systemwide strategy.

Insufficient inpatient bED capacity has been recognized as one of the most important contributors to ED overcrowding [2,4]. This problem is usually reflected by the number of admitted patients who experience extendED boarding time in the EDs (also referred to as access block) [5]. Interventions to reduce ED boarding for admitted patients may play an important role in reducing the degree and consequence of ED overcrowding.

One strategy designed to address this issue is called the full capacity protocol (FCP). Full capacity protocols have been implemented in an effort to increase the ED functional capacity by transporting admitted patients from the ED to temporary care spaces (eg, inpatient care spaces designed for admitted ED patients). The goal of the FCP is to safely share the burden of inpatients without assigned beds throughout the hospital, with the intent of improving clinical operations and mitigating the negative effects of ED overcrowding. Moreover, FCP interventions have been embedded within several systemwide interventions (SWIs) that have been implemented in an effort to improve the efficiency of admitted patients’ flow, liberate ED care spaces, and share the patient volume among inpatient services. Despite the promise of this intervention, the consequences and effec- tiveness of the intervention are largely anecdotal.

No systematic review has examined the role that an FCP plays on mitigating ED overcrowding; such information is crucial to support frontline staff’s and physicians’ decisions and to help ED administrators and policy-makers identify evidence-based strategies that may improve the quality of the

services provided in acute health care settings. Our objective was to search for the available evidence on FCPs, summarize the outcomes associated with this intervention, and deter- mine its effectiveness.

Methods

Study protocol

An a priori study protocol was used to define the search strategy, set the study selection criteria, outline quality assessment and data extraction procedures, and plan the analysis of the study results.

Search strategy

The search strategy developed for the Canadian Agency for Drugs and Technologies in Health (CADTH) report entitled “Interventions to reduce overcrowding in emergency departments” was updated for this study [1]. The original CADTH report involved literature searches from 1966 to December 2005; this study searched for citations between October 2004 and May 2009, both without restrictions on language or publication status. The overlapping was necessary to ensure that all the new literature indexed after the CADTH report would be considered for inclusion.

A comprehensive literature search was conducted in 7 biomedical electronic databases–MEDLINE, EMBASE, EMB Reviews-Cochrane Central Register of Controlled Trials, HealthSTAR, Science Citation Index Expanded, Dissertation Abstracts, and ABI/INFORM Global–using a vast number of keywords to identify relevant literature (see Appendix 1 for details). This search method was required because of the nonspecific cataloging of ED overcrowding in the literature and included common overcrowding words such as overcrowding, emergency department, access block, full capacity protocol, FCP, overcapacity, over capacity, etc. Clinical trial registries (ClinicalTrials.gov and controlled-trials. com) and Google Scholar web searches were also completed. Hand searching of abstract books and Web sites was performed to identify abstracts presented to the following major scientific conferences between October 2004 and May 2009: the Canadian Association of Emergency Physicians, the American College of Emergency Physicians, the Society of Academic Emergency Medicine, the College of

Emergency Medicine in the United Kingdom, and the Australasian College for Emergency Medicine. In addition, the references of identified articles were manually searched. Primary authors and experts in the field were contacted to identify additional published, unpublished, or ongoing studies. The search results from the CADTH report were merged with those of the updated searches, resulting in a comprehensive search strategy to identify potentially relevant studies published from 1966 to May 2009.

Study selection

Eligible studies were primary research that assessed the impact of the intervention of an FCP to mitigate the effect of overcrowding in EDs serving adult (17 years or older) or mixed (ie, child and adult) populations. Studies reporting results from isolated implementation of any FCP protocol or inclusion of an FCP protocol as part of an SWI were eligible. Studies with one of the following designs were considered for inclusion in the review: paralleled- or clustered-group randomized controlled trials (RCTs/cRCTs), Controlled clinical trials (CCTs), prospective or retrospective analytical cohort studies, interrupted time series (ITS), Case-control studies, and before-after designs. Studies were required to report numeric data on at least one of the following outcomes: ED length of stay (LOS; time in hours from patient arrival/triage to physically leaving the ED), hospital LOS (time in hours from patient admission to being discharged from the hospital), ED access block (the number of waiting room patients), and hospital access block (the number of boarded patients held in the ED). Nonprimary research (eg, editorials, commentaries, letters to the editor, narrative reviews, technology reports, and systematic reviews), studies conducted in pediatric EDs, duplicate publications/reports, and studies comparing 2 levels of the same intervention were excluded.

Two of 3 reviewers (BR, MO, and XG) independently screened titles and abstracts of studies identified by the literature search to eliminate clearly irrelevant studies. The full- text versions of articles deemed potentially relevant as well as those that reported insufficient information to determine eligibility were independently reviewed by 2 of 4 reviewers (BR, MO, CV, and LW). Any disagreements were resolved by consensus, although this was infrequent. Non-English literature was translated by foreign language reviewers (SMH and DS-F). Studies that met all inclusion criteria were eligible for quality assessment and data extraction.

Quality assessment

A standard quality-rating tool developed by the Effective Public Health Practice Project (EPHPP) was used to appraise the quality of the individual studies [6]. This tool is based on guidelines set out by Mulrow et al and Jadad et al, and has accepted validity and reliability [7-9]. The tool rating is

based on 6 criteria: selection bias, study design, confounders, blinding, data collection methods, and withdrawals and dropouts. Each criterion is rated as “strong,” “moderate,” or “weak” depending on information reported in the article. Once the ratings of characteristics are totaled, each study receives an overall assessment of strong (ie, 4 “strong” ratings with no “weak” ratings), moderate (less than 4 “strong” ratings and 1 “weak” rating), or weak quality (2 or more “weak” ratings). Two assessors (BR and XG) independently rated the quality of included studies, and discrepancies were resolved by consensus.

Data extraction

Two reviewers (LW and XG) independently extracted the data from all included studies. Information regarding the study design and methods (eg, year, country of origin, type of publication, study duration, number of participating centers, study design), intervention’s characteristics and comparisons, and outcomes of interest was extracted using a pretested data extraction form. Finally, information was collected on study conclusions, as reported by the authors of the primary studies. Any discrepancies in data extraction were resolved by consensus. Attempts were made to communicate with investigators for clarification or additional data.

Data analysis

An evidence table was constructed to report information on the article’s source, study design, study population, treatment groups, and outcomes. Meta-analyses were originally planned as a part of the data analysis to derive pooled estimates from individual studies; however, because of the small number of included studies, this was not feasible. Data are presented as means with their associated standard deviations for continuous outcomes. A P value b .05 was considered statistically significant.

Results

Search results

The systematic search resulted in the identification of

14 446 potentially relevant citations, from which 3615 studies clearly addressed the topic of ED overcrowding. After screening the studies’ titles and abstracts, 354 full articles were retrieved for further examination. The applica- tion of the selection criteria to the 354 studies resulted in the identification of 1 study reported in 2 abstracts that specifically assessed the effectiveness of an FCP. In addition, 29 studies on SWI were identified in the search, from which 4 contained an FCP component. Fig. 1 outlines the study selection flow for the review. The complete list of references of excluded studies is available upon request.

Fig. 1 Study selection flow for FCP systematic review. *Two independent reviewers using full articles.

Study characteristics

The only included study was a single-center ED study based on a before-after design (2 abstracts from the same study) [10,11]. In this study, arriving triage level I to III patients were placed in overcapacity ED care spaces rather than in waiting room areas; boarded patients were moved from the ED to inpatient overcapacity care spaces whenever ED was overcapacity by 2 patients.

The health care system where the FCP was implemented, the duration and design of the evaluation, and the triggers for implementing the FCP protocol varied among the 4 SWI interventions that contained an FCP component (Table 1). The FCP triggers varied; both time- (to meet the 4-hour ED rule) and volume- (number of admitted patients occupying ED stretchers) based triggers were reported. None of the studies reported on the system’s compliance with these protocol triggers.

Based on the EPHPP tool, the overall quality of the study was appraised as weak [6].

Study outcomes

In one of the identified abstracts, the authors reported results on ED and hospital LOS, whereas the ED and hospital access block were described in the other [10,11]. Compared with the preintervention period, there was a demonstrated

5-hour decrease in the mean ED LOS (18.9 vs 13.9 hours, P b .001) for all admitted patients in the ED when an FCP was in place. There was a global decrease in ED LOS for admitted medical (9-hour reduction), surgical (1.6-hour reduction) and mental health patients (9.2-hour reduction). Similarly, hospital LOS fell by 1.0, 0.8, and 0.8 days for medical, surgical, and mental health patients, respectively (P b .001 for all). In addition, ED access block and hospital access block were shown to have decreased by 28% and 37%, respectively (P b .001). The detailed characteristics of this study are presented in Table 1.

Discussion

This systematic review summarizes the best available evidence on the implementation of FCPs in an effort to mitigate the negative effects of ED overcrowding. Using a comprehensive and exhaustive search strategy, only one study that specifically evaluated the impact of an FCP on ED metrics was identified; however, this study has yet to be published in the mainstream scientific literature [10,11]. Overall, despite ED-volume increases, this study reported a 5-hour reduction in the mean ED LOS for all admitted patients following the FCP implementation. In addition, ED access block and hospital access block decreased by 28% and 37%, respectively. Reductions were consistent across all

Reference	Location	Sample size	Intervention period	Study design	Intervention	Comparison
Study assessing FCP
Innes et al,	Canada	61 329	6 mo	Before-after	FCP: whenever ED	Pre-FCP
2008 [10]					overcapacity by 2 patients,
Innes et al,					boarded patients were
2007 [11]					moved to inpatient care
					spaces. 2-h rule: maximum
					for ED assessment,
					2 h maximum from
					the decision to admit,
					2 h maximum to transfer
					patients to inpatient spaces.
Studies assessing SWI with an FCP		component
Schuur et al,	United States	7132	3 mo	Before-after	SWI with an FCP	Preintervention
2007 [18]					component: Patients were
					transferred to the floor at
					90 min post-bed
					assignment, regardless
					of unit acceptance.
Rowe et al,	Canada	NR	18 mo	CCT	SWI with an FCP: No more	Preintervention
2009 [19]					than 2 patients were placed
					on wards when “triggers”
					(based on ED size) were
					reached.
Mason et al,	United Kingdom	56 000	6 y	ITS	SWI with an FCP	Preintervention
2008 [20]					component: to meet the
					4-h target between arrival
					and discharge or admission;
					various protocols.
Cardin et al,	Canada	3621	12 mo	Before-after	SWI with an FCP	Preintervention
2003 [21]					component: transfer to
					ward within 1 h of bed
NR indicates not	reported; ITS, interrupted time series.				assignment.

hours of the day and there were no critical associated events, suggesting a consistent and apparently safe access block improvement during “busy” and “nonbusy” periods. Al- though this report is encouraging, there remains a paucity of comprehensive data available in the literature on this intervention to inform policy- and decision-makers with its adoption.

Table 1 Descriptive characteristics of the study included in the review

From 29 studies involving SWIs, we also identified 4 with different FCP components; however, we did not include their effectiveness data here, as this review focused on summa- rizing the outcomes associated with FCP as a single intervention. Moreover, the effectiveness data would be confounded by interventions other than the FCP contained within the SWI. Clearly, the evidence upon which we are arguing for or against FCP as a unique solution to ED overcrowding is weak.

To some, the lack of evidence may be surprising given the apparent popularity of FCP in the gray literature (eg, unpublished or hard to find literature). Since its original description by Dr AW Viccellio and successful implemen-

tation at the Stonybrook (NY) University Medical Center, many other sites have adopted this intervention [12-16]. There could be several potential reasons to this finding. First, administrators implementing FCP strategies may not for- mally evaluate their interventions or disseminate their evaluation findings. This may be the case especially when the studies do not confirm previous results (eg, negative studies). Second, it is time consuming and expensive to evaluate the impact of a large operational intervention such as the FCP, even in a single center. With the advent of computerized ED information systems, the availability, reliability, and validity of the LOS outcome measure should improve. Third, because most of the operations research studies in EDs are not RCTs or CCTs, they may be not registered and thus potentially fall below our screening strategy. Finally, and likely most importantly, many of these complex interventions are implemented by skilled adminis- trators without the research expertise and/or interest in knowledge dissemination. Whatever the cause(s), the paucity of evidence is an important finding of this systematic review

and does raise some concerns. Future evaluations of FCP implementation strategies should be encouraged, supported, and reported in a more rigorous manner.

The evidence cited here does not reflect all of the reports in the literature. There are a number of reports within the gray literature describing the use of FCPs that could not be included in this review. For example, several Canadian sites have described their implementation of an FCP; however, their evaluations have been descriptive and essentially uninterpretable [13,14]. One recent article identified after the original search was completed provided some insight to the particular circumstances and context that may surround this type of interventions [17]. This article reports the 4-year experience of a single suburban, university-based, academic ED in which FCP was implemented as an institutional policy in 2001. In this policy, boarded patients were transferred to inpatient hallways when the lack of an available ED bed for the next patient was documented. This study showed that most of these boarded patients were monitored patients with no condition that required intensive care or step-down units. Patients requiring strict vigilance, control, or isolation (eg, those presenting with chest pain and having a positive initial troponin test result; needing regular suction, High-flow oxygen, control of their seizures; or with neutropenia) were not eligible for hallway placement. Overall, 4% (n = 2042) of the total ED admissions (N = 55 062) during those 4 years went to a hallway location. Hallway admissions were more likely for patients arriving during the evening shift (4:00 PM to midnight: 4.5%) than those arriving during the overnight shift (midnight to 8:00 AM: 3.6%) and day shift (8:00 AM to 4:00 PM: 4.1%). The median ED LOS for patients admitted to standard and hallway beds were 426 (306, 600 minutes) vs 624 (439, 895 minutes), respectively (P b .001). Most of the evidence on the effectiveness of an FCP, including this last article, failed in our methodological screening and therefore were excluded from this systematic review.

Some other examples of FCPs buried within the SWIs have been undertaken by regions or hospitals, and these reports provide an important insight into the delivery of these interventions [18-21]. The description of the protocols suggested that the trigger for activating the FCP varied, and no 2 protocols were similar. For example, some protocols used time (2- or 4-hour waits) or volume (eg, overcapacity by 2 patients) or combined criteria to initiate the implementation. Moreover, the location of the FCP beds differed across the SWIs. Some patients were placed in hallways in full view of staff and visitors, whereas others were placed in rooms as an extra bed. These SWIs may have reduced the potential benefit of the intervention by placing these FCP cases out of sight. Very few studies discussed the compliance with the triggers that were implemented, or the commitment and accountability of upper management to the FCP strategy. Finally, there appears to be no standard definition of FCP, resulting in inconsistencies between methods used in practice.

Most studies, however, have not looked for potential downsides of FCP strategies. After reviewing all available evidence, it is apparent that there has not been a strong documentation of potential harms or drawbacks of enforcing FCP practices. Patients seem to prefer inpatient hallways rather than ED hallways as boarding locations, and many reasons could explain this (eg, patients’ location closer to their inpatient physicians’ other patients, plans of care implementation in a more rapidly and effectively manner) [22]. Further research is needed to be able to evaluate family and staff satisfaction. Finally, Infection control concerns, as well as costs, and health care provider concerns about care delivery (in a crowded room or a hallway) are other practical markers of effectiveness and adverse consequences that may provide additional guidance for FCP implementation in different acute settings.

Strengths and limitations

The following limitations should be acknowledged when interpreting the results of this review. First, the only study that specifically assessed the effect of FCPs on mitigating ED overcrowding was reported in abstract form and had missing data; however, our contact with the study investigators made possible the addition of original data. Second, anticipated meta-analyses, subgroup comparisons, and sensitivity anal- yses were not possible because of insufficient studies. Third, despite our comprehensive and detailed search strategy, it is possible that publication bias may have influenced our results. Recent evidence suggests that publication bias is less pervasive in the ED literature; however, negative trials are less likely to be published and more likely to be excluded from a review of this nature [23]. Finally, selection bias is possible; however, all abstracts and articles were screened by at least 2 independent reviewers using standardized eligibil- ity criteria in an effort to decrease the likelihood of this bias. There are several strengths of this review including a focused question, our efforts to reduce publication (compre- hensive searching techniques, including non-English- language and unpublished research) and selection (multiple

reviewers) bias, and the use of a quality scoring system.

Conclusion

In summary, the evidence upon which administrators, clinicians, and others base decisions about the implementa- tion of FCPs to address ED overcrowding is limited. Although ancillary evidence can be derived from SWI with an FCP component, the operational definitions of all FCP plans varied remarkably. This important field could benefit from a concerted effort by administrators and health service researchers to collaborate not only to improve the quality of the evaluation of FCP interventions, but also to promote a more comprehensive outcome reporting and a wider dissemination of ED overCrowding research.

Acknowledgments

	Table 1.1 (continued)
	String terms
	“Canadian Triage and Acuity Scale”.mp. ambulance$.ti,ab. or/18-30 17 and 31

The authors would like to thank the corresponding author, Dr Viccellio, for his responding to our request on additional data and clarification. The authors are grateful to Donna Ciliska and Donna Fitzpatrick-Lewis for their explanation on the EPHPP quality assessment tool and to Diana Satanovsky- Feldman and Siri Margrete Holm for their assistance in translation.

Table 1.2 EMBASE-Ovid version String terms

exp CROWDING/

crowd$.ti,ab.

overcrowd$.ti,ab.

gridlock$.ti,ab.

“access block$”.ti,ab.

warehous$.ti,ab.

(“Left without being seen” or “leave$ without being seen” or lwbs).ti,ab.

(ambulance$ adj2 diver$).ti,ab.

“fast track$”.ti,ab.

(wait$ adj2 time$).ti,ab.

*Health Services Misuse/

(misuse$ or overutili$).ti,ab.

((nonurgent or non-urgent or inappropriate or nonacute) adj5 (patient$ or visit$ or use$ or care or problem$ or attend$)).ti,ab.

(“length of stay$” or los).mp.

(length adj2 stay$).ti,ab.

(lama or (leave$ adj4 (“medical advice” or treatment$)) or (left adj4 (“medical advice” or treatment$))).ti,ab.

or/1-16

*emergency medical services/ or *emergency medical service communication systems/ or *emergency service, hospital/ or *trauma centers/ or *emergency services, psychiatric/ or *”transportation of patients”/ or

*ambulances/ or *Air ambulances/ or *triage/

(triage$ or “emergency medical service$ communication$ system$” or “trauma center$” or “trauma centre$” or “tranport$ adj2 patient$”).mp.

(emergenc$ adj2 (medical$ or health or hospital$ or psychiatric) adj2 service$).mp.

((“a and e” or “a & e” or a&e) adj1 (service$ or department

$)).ti,ab.

((emergenc$ or emerg or accident$ or casualt$) adj2 (service$ or department$ or room$ or centre$ or center$ or unit$)).ti,ab.

(“acute care” or “emergency care”).mp.

(emergicenter$ or emergicentre$).mp.

(((prehospital or pre-hospital) adj2 emergenc$ adj2 care$) or (“prehospital care” or “pre-hospital care”)).mp.

(emergenc$ adj2 (outpatient$ or out-patient$) adj2 unit$).mp.

((ems or ed or er) and emergenc$).mp.

(“observation unit$” or “observation area$” or “holding unit$” or “holding area$”).ti,ab.

“Canadian Triage and Acuity Scale”.mp.

ambulance$.ti,ab.

or/18-30

17 and 31

Appendix 1. Exact search strings

Table 1.1 MEDLINE-Ovid version String terms

exp CROWDING/

crowd$.ti,ab.

overcrowd$.ti,ab.

gridlock$.ti,ab.

“access block$”.ti,ab.

warehous$.ti,ab.

(“left without being seen” or “leave$ without being seen” or lwbs).ti,ab.

(ambulance$ adj2 diver$).ti,ab.

“fast track$”.ti,ab.

(wait$ adj2 time$).ti,ab.

*Health Services Misuse/

(misuse$ or overutili$).ti,ab.

((nonurgent or non-urgent or inappropriate or nonacute) adj5 (patient$ or visit$ or use$ or care or problem$ or attend$)).ti,ab.

(“length of stay$” or los).mp.

(length adj2 stay$).ti,ab.

(lama or (leave$ adj4 (“medical advice” or treatment$)) or (left adj4 (“medical advice” or treatment$))).ti,ab.

or/1-16

*emergency medical services/ or *emergency medical service communication systems/ or *emergency service, hospital/ or *trauma centers/ or *emergency services, psychiatric/ or *”transportation of patients”/ or

*ambulances/ or *air ambulances/ or *triage/

(triage$ or “emergency medical service$ communication$ system$” or “trauma center$” or “trauma centre$” or “tranport$ adj2 patient$”).mp.

(emergenc$ adj2 (medical$ or health or hospital$ or psychiatric) adj2 service$).mp.

((“a and e” or “a & e” or a&e) adj1 (service$ or department

$)).ti,ab.

((emergenc$ or emerg or accident$ or casualt$) adj2 (service$ or department$ or room$ or centre$ or center$ or unit$)).ti,ab.

(“acute care” or “emergency care”).mp.

(emergicenter$ or emergicentre$).mp.

(((prehospital or pre-hospital) adj2 emergenc$ adj2 care$) or (“prehospital care” or “pre-hospital care”)).mp.

(emergenc$ adj2 (outpatient$ or out-patient$) adj2 unit$).mp.

((ems or ed or er) and emergenc$).mp.

(“observation unit$” or “observation area$” or “holding unit

$” or “holding area$”).ti,ab.

References

Table 1.4 HealthSTAR (Health Services Technology, Administration, and Research)-Ovid version

String terms

exp CROWDING/

crowd$.ti,ab.

overcrowd$.ti,ab.

gridlock$.ti,ab.

Table 1.5 Science Citation Index Expanded String terms

Web of Science

TS = crowd* OR TS = overload* OR TS = emergency department* volume*

OR TS = gridlock OR TS = access block* OR TS = leave without treatment AND

TS = emergency medical service* OR TS = emergency service* OR TS = trauma center* OR TS = ambulance* OR TS = triage OR TS = prehospital care OR TS = acute care OR TS = emergency care OR TS = hospital emergenc* OR TS = emergency-department* OR TS = public hospital* emergenc*

Table 1.3 Central (EBM Reviews-Cochrane Central Register of Controlled Trials)-Ovid version

String terms

exp CROWDING/

crowd$.ti,ab.

overcrowd$.ti,ab.

gridlock$.ti,ab.

“access block$”.ti,ab.

warehous$.ti,ab.

(“left without being seen” or “leave$ without being seen” or lwbs).ti,ab.

(ambulance$ adj2 diver$).ti,ab.

“fast track$”.ti,ab.

(wait$ adj2 time$).ti,ab.

*Health Services Misuse/

(misuse$ or overutili$).ti,ab.

((nonurgent or non-urgent or inappropriate or nonacute) adj5 (patient$ or visit$ or use$ or care or problem$ or attend$)).ti,ab.

(“length of stay$” or los).mp.

(length adj2 stay$).ti,ab.

(lama or (leave$ adj4 (“medical advice” or treatment$)) or (left adj4 (“medical advice” or treatment$))).ti,ab.

or/1-16

*emergency medical services/ or *emergency medical service communication systems/ or *emergency service, hospital/ or *trauma centers/ or *emergency services, psychiatric/ or *”transportation of patients”/ or

*ambulances/ or *air ambulances/ or *triage/

(triage$ or “emergency medical service$ communication$ system$” or “trauma center$” or “trauma centre$” or “tranport$ adj2 patient$”).mp.

(emergenc$ adj2 (medical$ or health or hospital$ or psychiatric) adj2 service$).mp.

((“a and e” or “a & e” or a&e) adj1 (service$ or department

$)).ti,ab.

((emergenc$ or emerg or accident$ or casualt$) adj2 (service$ or department$ or room$ or centre$ or center$ or unit$)).ti,ab.

(“acute care” or “emergency care”).mp.

(emergicenter$ or emergicentre$).mp.

(((prehospital or pre-hospital) adj2 emergenc$ adj2 care$) or (“prehospital care” or “pre-hospital care”)).mp.

(emergenc$ adj2 (outpatient$ or out-patient$) adj2 unit$).mp.

((ems or ed or er) and emergenc$).mp.

(“observation unit$” or “observation area$” or “holding unit$” or “holding area$”).ti,ab.

“Canadian Triage and Acuity Scale”.mp.

ambulance$.ti,ab.

or/18-30

17 and 31

	Table 1.4 (continued)
	String terms
	“access block$”.ti,ab. warehous$.ti,ab. (“left without being seen” or “leave$ without being seen” or lwbs).ti,ab. (ambulance$ adj2 diver$).ti,ab. “fast track$”.ti,ab. (wait$ adj2 time$).ti,ab. *Health Services Misuse/ (misuse$ or overutili$).ti,ab. ((nonurgent or non-urgent or inappropriate or nonacute) adj5 (patient$ or visit$ or use$ or care or problem$ or attend$)).ti,ab. (“length of stay$” or los).mp. (length adj2 stay$).ti,ab. (lama or (leave$ adj4 (“medical advice” or treatment$)) or (left adj4 (“medical advice” or treatment$))).ti,ab. or/1-16 *emergency medical services/ or *emergency medical service communication systems/ or *emergency service, hospital/ or *trauma centers/ or *emergency services, psychiatric/ or *”transportation of patients”/ or *ambulances/ or *air ambulances/ or *triage/ (triage$ or “emergency medical service$ communication$ system$” or “trauma center$” or “trauma centre$” or “tranport$ adj2 patient$”).mp. (emergenc$ adj2 (medical$ or health or hospital$ or psychiatric) adj2 service$).mp. ((“a and e” or “a & e” or a&e) adj1 (service$ or department $)).ti,ab. ((emergenc$ or emerg or accident$ or casualt$) adj2 (service$ or department$ or room$ or centre$ or center$ or unit$)).ti,ab. (“acute care” or “emergency care”).mp. (emergicenter$ or emergicentre$).mp. (((prehospital or pre-hospital) adj2 emergenc$ adj2 care$) or (“prehospital care” or “pre-hospital care”)).mp. (emergenc$ adj2 (outpatient$ or out-patient$) adj2 unit$).mp. ((ems or ed or er) and emergenc$).mp. (“observation unit$” or “observation area$” or “holding unit$” or “holding area$”).ti,ab. “Canadian Triage and Acuity Scale”.mp. ambulance$.ti,ab. or/18-30 17 and 31

Table 1.6 Dissertation Abstracts String terms

ProQuest

(((Overcrowding) OR (crowding) OR (access block) OR (left without being seen) AND (emergency))) AND PDN(N10/1/ 2004)

ABI/INFORM Global ProQuest

(((Overcrowding) OR (crowding) OR (access block) OR (left without being seen) AND (emergency))) AND PDN(N10/1/ 2004)

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