Emergency Department Overcrowding: An Action Plan
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ACADEMIC EMERGENCY MEDICINE February 2001, Volume 8, Number 2 185
Emergency Department Overcrowding:An Action Plan
From the time I began work-ing in emergency depart-ments (EDs) in New York City asa full-time profession in 1980 un-til I left the city in 1988, I do notrecall a single shift at any timeof day or night, in any of five dif-ferent EDs, on any day or in anyweek, month, or year, wherethere were not admissionsstacked up knee-deep in the ED.The entire borough of Queensran at over 100% occupancyevery day for more than a year.When holding 30 admitted pa-tients in a ten-bed ED, I oncecalled a nearby ED to attempttransfer of some of our admittedpatients. The receiving ED po-litely declined the transfers, asthey were holding more than 50admitted patients in their ED.We had been averaging 20 ad-missions held in the ED on eachshift for an entire year. In 1987,I had the opportunity to treat a45-year-old male (a malpracticelawyer, as is usual for such sto-ries) with an acute anterior wallmyocardial infarction. He repre-sented the first time in my careerI had ever provided the first mo-ments of care to a patient on ablanket on the floor of our ED,having utilized all our stretch-ers, the hospitals stretchers, andadditional stretchers brought inby an outside company.
Interestingly, it simply neveroccurred to me at that time to de-mand that some of these admit-ted patients be moved up to hall-ways on the inpatient units;after all, there was a lot morehallway space upstairs than inour tiny ED. I, like most involvedin emergency medicine (EM),had simply become acclimatized(brainwashed?) to the notionthat this, of course, was bothunsafe and undoable. It justseemed natural to keep the pa-
tients in the ED, and to becomenarcotized by our daily Sisy-phean drama.
New York and California wereparticularly active during thisperiod, the mid-80s, at bringingthis issue to the public. Articlesin the New York Times and majormagazines appeared. Nationalnews shows featured stories onthe crisis of ED overcrowding.It made for great story. Similarstories recycled in the mid- tolate 90s. Overcrowding didntreach Suffolk County, where Iwork now, until four or five yearsago. When it did, it was worthyof a CNN special report.
What was lacking, however,was any useful solution to theproblem. Ambulance diversionwas tried with little success,given that entire regions weresaturated with patients. Direc-tives to cancel elective admis-sions were issued, but electiveadmissions were, by that time, athing of the past. Hospitals inNew York were cited for not pro-viding adequate privacy, for notdocumenting repeatedly on thepatients chart that an inpatientbed was not available, for notcalling in additional staff (whichdidnt exist) to provide neededcare, and for not providing theappropriate nursing ratios to in-tensive care unit (ICU) patientsboarding in the ED. The EDnurses began completing the ten-page admission forms for the ad-mitted patients. We were re-quired to go through the motionsof attempting transfer, request-ing ambulance diversion, andother steps that we knew heldlittle hope of relief. We collecteddaily stats in New York City onovercrowding. As it got worse,the response was to collect statsevery shift. When we wouldmeet to discuss why physicians
werent discharging patients,why nurses werent reportingavailable beds, there would beanother round of studying anddocumenting. Meanwhile, a fairnumber of patients spent theirentire hospitalizations in thehallway of an ED.
From the mid-80s andthrough the 90s, another themecame crashing down on our at-tempts to deal with ED over-crowdingthe unnecessary ornonurgent ED visit. In one fellswoop, this became the cause ofED overcrowding, as well as thecause of the ever-increasing na-tional health care costs. Therewas now no longer any reason tofix ED overcrowding. Why throwresources at this reprehensiblegroup of people who were justabusing the system? The obvious(though impossible) solution wassimply to send all those unnec-essary visits away. Suddenly wehad been transformed into anoverstaffed and overpriced walk-in clinic. Studies that showed wewere paid half of charges wereinterpreted to mean we chargetwice as much. All of this openedthe floodgates to denial of pay-ment for care rendered. Worse,we became the first (and probablylast) profession to actively concep-tually agree, via the AmericanCollege of Emergency Physicians(ACEP)Kaiser agreement andprudent layperson laws, thatthere are some patients we haveto take care of but should not bepaid for. The idea that we occa-sionally take care of real emer-gencies seemed permanently lostin these discussions. Even recentarticles that attempt to legiti-mize ED overcrowding as a realissue, such as last years flu epi-demic, suggest that, once the flugoes away, then so will over-crowding.2 Thankfully, the tele-vision show ER has served toremind the public that we are inthe business of saving their lives.
The article, by Drs. Derlet,Richards, and Kravitz in this is-sue of Academic Emergency Med-
186 COMMENTARIES Viccellio OVERCROWDINGACTION PLAN
icine1 brings us full circle back tothe real problem of ED over-crowdingtoo many sick pa-tients, and too many admittedpatients. In this survey of a ran-dom sample of EDs in the UnitedStates, 91% of the 575 respond-ing ED directors reported over-crowding as a problem. Evengranting the obvious limitationsof a survey, the results resonatewith the experience of manyemergency physicians. The re-spondents definition of over-crowding was all too familiarpatients in hallways, all ED bedsoccupied, full waiting rooms, andacutely ill patients waiting forprolonged times to be seen. Thetop causes of overcrowding, asreported by the respondents,were high patient acuity, hospi-tal bed shortage, high ED pa-tient volume, delays in lab andradiology, and insufficient EDspace. The type and location ofthe hospital mattered little. Itcame as somewhat of a surpriseto me that only 30% reportedthat overcrowding has alwaysbeen a problem. Half reportedthat the problem had occurred inthe past several years. Impor-tantly, but not surprisingly, theED directors also reported sig-nificant delays in treating sickpatients, with a high risk or ac-tual occurrence of bad outcomedue to overcrowding.
I would have liked to see sev-eral other questions included inthis survey. Specifically, if theED were not to hold admitted pa-tients at all, would they still ex-perience a significant, sustainedproblem with overcrowding?How often were patients held inthe ED in spite of available in-patient beds because of lack ofadequate inpatient staff? How of-ten were numbers of ICU pa-tients held in the ED with nodedicated staff to care for thembecause staff ratios in the ICUneeded to be preserved? How of-ten were admitted patients heldin the ED in the face of continu-ing transfers to the inpatient
units for specialty care (in par-ticular, cardiac catheterizationand surgery)? How many sitesactually have extra staff avail-able as backup when admittedpatients fill the ED? How soon,and how often, did the admittingphysician see the patient whileboarding in the ED? Was emer-gency care ever compromisedsolely because of a high volumeof low-acuity patients? And, fi-nally, how many nurses haveburst into tears during theirshift because they were simplyoverwhelmed by the needs oftheir patients?
The overall picture painted bythese findings is one of acutely illpatients arriving at the ED, theirtreatment delayed, and thenonce treated, never leaving, lead-ing to an ever-growing popula-tion of sick patients spendingtheir most critical hours anddays in an area not designed toprovide such a service. It is im-portant not to confuse the issueof overcrowding with the issueof the ED as a safety net. Richand poor alike routinely lack ac-cess to an appropriate inpatientbed. Their hospitalization occurswithout space, specialist, or ser-vice.
Why do admitted patients re-main in the ED? It is indeed astrange acquiescence on our partto embrace the notion that, whenhospitals have no inpatient beds,the patient will naturally have toremain in the hallway of an ED.(Even stranger is how they re-main in the ED when there areinpatient beds.) This logic, oneshould note, is differentially ap-plied. Obstetrical patients dontremain in EDs; they are movedto the obstetrical suite, regard-less of occupancy. It is illogicalthat this does not occur in otherareas of the hospital, which hasfar greater square footage thanthe ED. The suggestion of hoard-ing patients in the operatingroom would be met with ridicule,for obvious reasons. Why is it notobvious that the critical ability
of the ED to function as an EDcannot similarly be subverted?Should the door-to-needle timebe dependent upon the inpatientphysician who wont dischargehis or her patient, the nurse whodoesnt report the empty bed toadmitting, or the housekeeperwho wont clean the room?
Hospitals are peculiarly mis-shapen institutions. Most werebuilt and organized in an era ofelective admissions, and prior tomany advanced procedures suchas cardiac bypass. The bulk ofbusiness, being elective, couldproceed without difficulty withinthe context of a 9-to-5 Monday-through-Friday schedule. It wasperfectly appropriate in this con-text to reduce staff on eveningsand weekends. Hospitals gener-ally enjoyed an excess of ICUbeds. How things have changed!Most admissions are now un-scheduled, and the acuity leveland need for ICU beds havesoared. Unfortunately, this hasoccurred without a significantchange in the weekday organi-zational philosophy and struc-ture of the hospital.
At the same time, ED vol-umes and acuity have soared.This is only part of the story,however. As the volume has in-creased, so has the sophistica-tion of the workup. The patientpreviously admitted for abdomi-nal pain now undergoes exten-sive testing and imaging in theED. I frequently tell