Emergency Department Overcrowding

Figure: John B. McCabe, MDConsider the following patients: ▪ A 20-year-old has recently sustained head trauma and has a ventriculostomy. The nurses note increasing intracranial pressure and place a call to the neurosurgery resident. ▪ A 50-year-old man is ready for discharge after a 48-hour hospital admission to investigate the cause of his substernal chest pain. ▪ A family anxiously waits at the bedside of an adolescent girl with asthma who is about to be extubated following a brief but severe acute exacerbation of her condition. These seem like typical patients in the intensive care units and medical units of our hospitals. Unfortunately, it is just as likely that they may never have reached those units but instead are still in the emergency department, where they have had to remain since the time of their hospital admission. Overcrowding of our nation's emergency departments, an intermittent, geographically isolated phenomenon in the 1980s, has reemerged as a widespread, chronic, and debilitating situation today. Overcrowding has a negative impact on patient care, on the missions of an academic medical center, and on the health of a community. Emergency department overcrowding is hard to define but easy to recognize. A stroll through an emergency department with patient stretchers in all the hallways, with conference rooms and offices converted to patient care space, a crowded waiting room, and harried nurses and physicians is clearly a walk through an overcrowded department. More specifically, a number of circumstances are widely recognized as signs of overcrowding. These include (1) patients' having to wait longer than 90 minutes to see a physician, (2) all department beds being filled with patients more than six hours per day, (3) patients' being placed in the hallways more than six hours a day, (4) more than 30% of department beds being filled with patients who are “admitted” to the hospital, and (5) having a full waiting room with no place for new patients more than six hours per day. WHY OVERCROWDING? Many factors contribute to emergency department overcrowding: Hospital and emergency department closings. Nationwide, the numbers of emergency departments and hospital beds have decreased through the downsizing, closing, and merging of health care institutions. A community with the same population, the same primary care providers, but fewer hospital and emergency department beds will naturally have more crowded emergency departments. Increasing volume and severity of illnesses of emergency department patients. Year after year, emergency department patient volumes continue to rise. The shift to outpatient services has resulted in sicker patients arriving in the emergency department to be admitted to the hospital. Thus, more patients and longer evaluation and treatment times in the emergency department. The nursing shortage. The current nationwide nursing shortage has caused many hospitals to close available inpatient beds. Having fewer inpatient beds means there are fewer places for admitted emergency department patients to go. The uninsured. The growing number of uninsured and underinsured patients results in more use of the emergency department, delays in seeking needed medical attention, and a worse health status when patients do seek treatment. Economic triage. Many hospitals are choosing to admit elective cases, which will result in higher payments, rather than allocating available beds to admitted and waiting emergency department patients, thus contributing further to the overcrowding of their emergency departments. Difficulty in obtaining timely consultations. Emergency physicians often find it difficult to obtain timely consultations from hospital medical staff. Emergency physicians must make alternate arrangements or transfer patients to other facilities for necessary care. Consultative delays endanger patients and often leave them waiting for hours for consultation and/or transfer. Timely access to ancillary services. Emergency medicine has evolved as an intensively diagnosis-oriented specialty that relies heavily on ancillary services. Often there is an irreconcilable mismatch between the needs of the emergency physician—vis à vis the diagnosis and management of acutely ill and injured patients—and the timelines of services from the departments of radiology and clinical pathology. These delays are aggravated by the shortages of radiology and laboratory technicians. This leads to long delays for patients. Availability of nursing home beds. The lack of adequate nursing home facilities makes discharging patients from the hospital difficult, thus keeping beds occupied. As a result, the admitted emergency department patient has no place to go. It should be noted that one of the “whipping boys” of the 1980s for emergency department overcrowding was the “unnecessary emergency department patient visit.” It was thought that patients arriving in the emergency department with simple complaints (e.g., ankle sprain, cold, medication prescription refill, etc.) were clogging up the system and were the cause of emergency department overcrowding. This was not true then and is not true now. Emergency department overcrowding occurs primarily when sick patients, evaluated by the emergency physician and admitted to the hospital, have no place to go and remain in the emergency department. It is mainly a symptom of an overcrowded hospital, not a result of “inappropriate” emergency department use. Emergency department overcrowding can have a negative impact on the care of individual patients. The admitted patient must compete with other admitted patients and newly arriving emergency department patients for nursing staff and physicians' time. Nurses are often asked to provide inpatient care. Many emergency department nurses are not trained in or comfortable with such care. The solution often is to have nurses “float” from inpatient units to the emergency department. The “float” nurse is often in an unfamiliar and frightening environment. In communities where tertiary care is provided, emergency department overcrowding shuts off the availability of such care to outlying communities. The full hospital leaves no place for a patient to be directly admitted, and the overcrowded emergency department makes it impossible to take an additional transfer patient. Emergency department overcrowding has a negative impact on the emergency department's nurses and physicians. In the most overcrowded emergency departments, nursing staff are busy all the time and are often asked to take care of problems they are not trained to handle. Emergency physicians often feel that they are providing care to admitted patients and are unable to attend to new emergency department patients. In the academic medical center, emergency department overcrowding creates another set of problems. Emergency medicine residents and medical students have a skewed educational experience, as many of the patients they see are admitted patients receiving intensive care and/or floor care. Patients who have emergent ambulatory problem often sit for hours in the waiting room and leave before being treated. The ability to conduct clinical research in the emergency department is severely restricted, as there is little flexibility and often no available nursing or ancillary staff, as they are busy caring for admitted patients. The tertiary care patient transfers, so vital to the education of other specialty and subspecialty residents, are often blocked. WHAT CAN BE DONE? There are at least three major changes in national policy that would help to ease overcrowding. The first is to decrease the number of uninsured and underinsured patients. Second, new incentives must be put in place for individuals to enter the nursing and health professions and to stay in the hospital environment. Third, there must be improved Medicaid and Medicare reimbursement rates, especially for our nation's urban and teaching hospitals. The leader in every hospital should think strategically and define what they want from their emergency department and then design a system of care around it that allows the department to meet these expectations. The emergency department may be viewed simply as a “loss leader” that requires necessary support. It may be viewed as an important medical and public relations portal of entry for patients to the hospital. It may be viewed as an ever-expansible area that will be staffed to meet the overflow issues of the hospital. It may be viewed as a place to capture a new market and patients for entry into primary care practices. It may be viewed as a site for tertiary care referral. For each of these scenarios, a different level of resource utilization and staffing and organizational structure is required. Emergency department overcrowding must be viewed as a hospital problem with hospital solutions, not just an emergency department problem with emergency department solutions. There is an “out of sight, out of mind” mentality towards emergency department overcrowding in many institutions. The solution to this overcrowding cannot be accomplished solely by asking the emergency department to close its doors or to expand infinitely to meet patient demand. On-call specialists and ancillary services must be available to emergency departments in a manner that expedites patient care and meets the expectations of emergency physicians and their patients. This can occur only as the result of serious discussions by the leaders of the different specialties at the national, local, and institutional levels. Research into the impact of emergency department overcrowding on patient outcome must be undertaken by the specialty of emergency medicine. What is the impact of a 72-hour emergency department stay? What is the impact on patients whose physicians have requested their transfer to a tertiary care center and whose transfers are delayed and/or denied? That same specialty must undertake research to determine which emergency department and hospital changes will fix overcrowding. Will providing a bigger emergency department solve the problem? Will the development of observation units or short-stay diagnosis and treatment units help? What is the optimal number of nursing and ancillary staff in the emergency department? Communities must work cooperatively during times of emergency department overcrowding. It makes no sense for one hospital in a community to be taking new emergency department patients while another closes its doors to ensure that elective surgical patients can be accommodated. Community-wide policy must be in place. Putting the necessary solutions in place will not be easy: emergency department overcrowding is not amenable to a “quick fix”; rather, it is a visible symptom of a troubled health care system. It is a symptom of inadequate resources, workforce shortage, and poor community planning. But nothing less than the quality of patient care is at stake. For that reason, we should all be committed to doing whatever must be done to lessen and eventually eliminate emergency department overcrowding.