International perspectives on emergency department crowding.

The maturation of emergency medicine (EM) as a specialty has coincided with dramatic increases in emergency department (ED) visit rates, both in the United States and around the world. ED crowding has become a public health problem where periodic supply and demand mismatches in ED and hospital resources cause long waiting times and delays in critical treatments. ED crowding has been associated with several negative clinical outcomes, including higher complication rates and mortality. This article describes emergency care systems and the extent of crowding across 15 countries outside of the United States: Australia, Canada, Denmark, Finland, France, Germany, Hong Kong, India, Iran, Italy, The Netherlands, Saudi Arabia, Catalonia (Spain), Sweden, and the United Kingdom. The authors are local emergency care leaders with knowledge of emergency care in their particular countries. Where available, data are provided about visit patterns in each country; however, for many of these countries, no national data are available on ED visits rates or crowding. For most of the countries included, there is both objective evidence of increases in ED visit rates and ED crowding and also subjective assessments of trends toward higher crowding in the ED. ED crowding appears to be worsening in many countries despite the presence of universal health coverage. Scandinavian countries with robust systems to manage acute care outside the ED do not report crowding is a major problem. The main cause for crowding identified by many authors is the boarding of admitted patients, similar to the United States. Many hospitals in these countries have implemented operational interventions to mitigate crowding in the ED, and some countries have imposed strict limits on ED length of stay (LOS), while others have no clear plan to mitigate crowding. An understanding of the causes and potential solutions implemented in these countries can provide a lens into how to mitigate ED crowding in the United States through health policy interventions and hospital operational changes.

[Implementation of the curriculum for specialist training in Emergency Medicine: room for improval on details]. / Implementatie van het curriculum voor de opleiding tot Spoedeisende Hulp(SEH)-arts: zoektocht naar het verborgen curriculum.

OBJECTIVE: To investigate what aspects of the new curriculum for specialist training in Emergency Medicine are actually implemented in daily practice. DESIGN: Descriptive study. METHOD: The curriculum was implemented as a pilot in 4 teaching hospitals, where a total of 32 residents in training in Emergency Medicine and 20 Emergency Medicine Program directors and Emergency physicians were surveyed using a web-based questionnaire querying the use of the different aspects of the curriculum in daily practice. RESULTS: Responses were received from 29 residents in training and 15 program directors and Emergency physicians. Both residents in training and program directors rated the patient mix seen during the training programme adequate to excellent. No great differences were observed in how residents in training, trainers and physicians working in the Emergency Department assessed the curriculum. However, the results showed that the training plan should be discussed explicitly with each residents in training. More attention should be focussed on the Society Awareness, Knowledge and Science and Organisation competencies and the Disability and Dermatology themes. Competence-based assessment methods, such as multi-source feedback, specific to this type of curriculum have not yet been sufficiently implemented. CONCLUSION: The responses to the questionnaire demonstrated how the curriculum is handled in daily practice and provided information on the progress of the implementation of the curriculum. This will enable focussed feedback to teaching hospitals.