title: Effect of an independent-capacity protocol on overcrowding in an urban emergency department.
abstract: OBJECTIVE
  The authors hypothesized that a new strategy, termed the independent-capacity protocol (ICP), which was defined as primary stabilization at the emergency department (ED) and utilization of community resources via transfer to local hospitals, would reduce ED overcrowding without requiring additional hospital resources.
  
  
  METHODS
  This is a before-and-after trial that included all patients who visited an urban, tertiary care ED in Korea from July 2006 to June 2008. To improve ED throughput, introduction of the ICP gave emergency physicians (EPs) more responsibility and authority over patient disposition, even when the patients belonged to another specific clinical department. The ICP utilizes the ED as a temporary, nonspecific place that cares for any patient for a limited time period. Within 48 hours, EPs, associated specialists, and transfer coordinators perform secondary assessment and determine patient disposition. If the hospital is full and cannot admit these patients after 48 hours, the EP and transfer coordinators move the patients to other appropriate community facilities. We collected clinical data such as sex, age, diagnosis, and treatment. The main outcomes included ED length of stay (LOS), the numbers of admissions to inpatient wards, and the mortality rate.
  
  
  RESULTS
  A total of 87,309 patients were included. The median number of daily patients was 114 (interquartile range [IQR] = 104 to 124) in the control phase and 124 (IQR = 112 to 135) in the ICP phase. The mean ED LOS decreased from 15.1 hours (95% confidence interval [CI] = 14.8 to 15.3) to 13.4 hours (95% CI = 13.2 to 13.6; p < 0.001). The mean LOS in the emergency ward decreased from 4.5 days (95% CI = 4.4 to 4.6 days) to 3.1 days (95% CI = 3.0 to 3.2 days; p < 0.001). The percentage of transfers from the ED to other hospitals decreased from 3.5% to 2.5% (p < 0.001). However, transfers from the emergency ward to other hospitals increased from 2.9% to 8.2% (p < 0.001). Admissions to inpatient wards from the ED were significantly reduced, and admission from the emergency ward did not change. The ED mortality and hospital mortality rates did not change (p = 0.15 and p = 0.10, respectively).
  
  
  CONCLUSIONS
  After introduction of the ICP, ED LOS decreased without an increase in hospital capacity.
authors.affiliation: From the Department of Emergency Medicine (WCC, SDS, KJS, SKJ, GJS), Seoul National University College of Medicine, Seoul, Korea.
authors.forename: Won Chul
authors.initials: WC
authors.lastname: Cha
authors.affiliation: From the Department of Emergency Medicine (WCC, SDS, KJS, SKJ, GJS), Seoul National University College of Medicine, Seoul, Korea.
authors.forename: Sang Do
authors.initials: SD
authors.lastname: Shin
authors.affiliation: From the Department of Emergency Medicine (WCC, SDS, KJS, SKJ, GJS), Seoul National University College of Medicine, Seoul, Korea.
authors.forename: Kyoung Jun
authors.initials: KJ
authors.lastname: Song
authors.affiliation: From the Department of Emergency Medicine (WCC, SDS, KJS, SKJ, GJS), Seoul National University College of Medicine, Seoul, Korea.
authors.forename: Sung Koo
authors.initials: SK
authors.lastname: Jung
authors.affiliation: From the Department of Emergency Medicine (WCC, SDS, KJS, SKJ, GJS), Seoul National University College of Medicine, Seoul, Korea.
authors.forename: Gil Joon
authors.initials: GJ
authors.lastname: Suh
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D002675:Child, Preschool; D002985:Clinical Protocols; D003441:Crowding; D017598:Efficiency, Organizational / Q000592:standards* / Q000706:statistics & numerical data; D004636:Emergency Service, Hospital / Q000458:organization & administration* / Q000706:statistics & numerical data; D005260:Female; D017052:Hospital Mortality; D006752:Hospital Planning / Q000379:methods*; D006786:Hospitals, Urban / Q000458:organization & administration* / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D010343:Patient Admission / Q000706:statistics & numerical data; D010360:Patient Transfer / Q000706:statistics & numerical data; D056910:Republic of Korea / Q000453:epidemiology; D055815:Young Adult