Overcrowding: Not Just an Emergency Department Issue

Patricia Kunz HowardDepartment, UniversitClinical Manager, CarCollege of Nursing, isE-mail: Pkhoward@uk

J Emerg Nurs 2005;31

0099-1767/$30.00

Copyright n 2005 by

doi: 10.1016/j.jen.200

P R E S I D E N T ’ S M E S S A G E

June 2005 31:3

Patricia Kunz Howard, PhD, RN, CEN,

Lexington, Ky

Emergency nurses struggle with over-

crowding each and every day. The reality of trying to

provide care for sicker patients, inpatients, and more

patients than the emergency department’s physical space

can handle has created an overcrowding situation that

extends well beyond the emergency department. As

emergency nurses, we work tirelessly to meet the demands

placed on us and our profession to care for our patients.

How much further can the seams of an overburdened

system be stretched? What is being done to address this

problem, and how did this challenging situation emerge?

In the early 1990s, it was forecasted that managed care

would result in the need for very few inpatient beds and

that emergency departments would only see patients with

major trauma. These predictions were just one of the

reasons that nursing was not a sought-after profession. As

nursing school enrollments decreased, so did nursing fac-

ulty positions, paving the way for what is said to be the

worst nursing shortage in history. According to a 2004 Na-

tional League for Nurses study, more than 125,000 quali-

fied applicants were turned away from nursing schools

last year, with inadequate nursing faculty being the main

, Staff Development Specialist, Emergencyy of Kentucky Hospital, and Research Protocoldiovascular Nursing, University of KentuckyPresident of the Emergency Nurses Association;y.edu.

:227-8.

the Emergency Nurses Association.

5.04.005

reason. It is a tragedy that we are in a situation that is only

expected to get worse, yet we are unable to produce the

resource we need the mostZnurses.The nursing shortage is one of most obvious factors in

the current overcrowding crisis. Many emergency nurses

provide care for inpatients every shift they work. In many

cases, this situation is not because of the lack of a physi-

cal bed to send the patient to, but a lack of a staffed bed.

Hospitals have had to close beds to provide safe and effec-

tive care for existing inpatients based on available nursing

staff. Most hospitals have a response plan for when they

are ‘‘closed to admissions’’; hospital closures do not stop

patients from continuing to seek care in the emergency

department, however. Patients still present to the emer-

gency department, on the advice of their primary care

provider or purely based on their own perceived need for

medical care.

The emergency department is viewed as a safe haven

by the public, a place to go for care when they are ill or

injured. It is becoming increasingly difficult to be able to

meet the needs of our patients because of the overcrowd-

ing crisis. In the past, diversion was used successfully as

a safety valve for an overcapacity emergency department.

Legislation has mandated that emergency departments may

only divert patients when capacity exceeds the capabilities

of the departmentZan all too frequent occurrence. Today,

diversion provides little relief for overcrowding. All the

facilities in a given area may already ‘‘be on divert,’’ ren-

dering diversion unrealistic, or the hospital needing to

divert patients may be the only hospital in the area.

Overcrowding is not just an ED issue; it is a systems

issue, and many persons have chosen to use the term

‘‘hospital overcrowding,’’ which is more ref lective of what

is truly occurring with an increasing frequency across the

JOURNAL OF EMERGENCY NURSING 227

P R E S I D E N T ’ S M E S S A G E / H o w a r d

United States. ENA has made overcrowding our strategic

priority. In an article about ED crowding, the author

asserts: ‘‘ED crowding should be on the political agenda

of every nursing professional organization’’ (see page 243).

ENA has put overcrowding on its agenda. ED crowding is

delineated in the recently released 2005Q2006 Public Policy

Agenda. ENA is working to address this issue through ad-

vocacy, research, and awareness. We need our colleagues to

do the same. Overcrowding is not just an emergency de-

partment issue; it is an issue of an overburdened health

care system.

Where do we go from here? Across the United States,

successful, innovative approaches are being used to lessen

the burden of hospital overcrowding on the emergency

department. These solutions include sending ED hallway

patients to the inpatient unit as hall patients, creating clini-

cal decision units, and maximizing departmental efficiency,

admission, and discharge and transfer units. One of the

greatest benefits of being an emergency nurse is our innate

desire to help our colleagues. If your facility has imple-

mented a strategy that has made a difference, share this

information with your peers. We are all in this together; we

need to work together to help address the problem.

228 JOURNAL OF EMERGENCY NURSING 31:3 June 2005