Background: Pediatric Emergency Department (PED) overcrowding is a threat to patient safety and can lead to medical errors, decreased quality of care, prolonged length of stay, as well as delays or denials of inbound patient transports. Purple Alert (PA) is an institutional capacity management policy designed to allow for decompression of PED patient census and activated “when the acuity or volume of patients exceeds the capabilities of the PED to provide safe and appropriate care to all patients.” One of the policy’s procedures states that new transports will not be accepted while the PED is on PA. Purpose: The aims were to (1) determine the proportion of transport denials attributable to PA activation and (2) describe the circumstances of the PED during PA activation, including measures of crowding, in order to inform future strategies to reduce transport denials. Methods: This study was conducted at a 30 bed, urban, academic PED with approximately 34,000 annual visits. The Pediatric Transport Service is available 24 hours a day to provide interfacility transports by ground or air and arranges transport for approximately 3,000 patients annually. Pediatric Transport Service records were reviewed from fiscal years (FY) 2017 and 2018 to determine the proportion of transport denials attributable to PA activation. PA checklists were reviewed from January 2019 (first month of availability) through March 2019; these records include total number of patients in the PED, patients in waiting area, current PED provider staffing, inpatient capacity, and pending inbound transports and referrals. The PED staff record these variables at the time of PA activation. The PA checklist also includes the ED Work Index (EDWIN) saturation score. This tool uses a three-category scale to measure crowding; scores >2.0 are indicative of the PED being extremely busy and severely overcrowded. Descriptive statistics were used for analysis. Results: During the 7/1/16-6/30/18 study period, there were 202 transport denials. Factors noted to contribute to transport denial included lack of inpatient beds, PA activation, and no transport team currently available (Figure 1). In FY 2017 and 2018, 9/93 (10%) and 23/109 (21%) transport denials occurred due to PA. Between January-March 2019, the PED activated PA a total of 12 times. Mean PED patient census was 38.6 patients (median 39). Mean EDWIN score was 2.46 (median score 2.70), indicating that the PED was extremely busy and severely overcrowded. Accepted pending transports/referrals ranged from 0-4 during PA activation, with a mean of 2.4. Conclusions: PA activation contributed to a significant proportion of transport denials and corresponded to PED busyness and overcrowding. Future directions include quality improvement efforts to standardize PA activation using objective measures such as the EDWIN score and PED decompression processes to reduce PED patient census.

Transport Denials

Number of Transport Denials Due to Various Factors