system dynamics and dysfunctionalities: levers for overcoming emergency department overcrowding

PRESENTATION

System Dynamics and Dysfunctionalities:Levers for Overcoming EmergencyDepartment OvercrowdingGordon D. Schiff, MD

AbstractOvercrowding of U.S. emergency departments (EDs) is a widely recognized and growing problem. Thispresentation offers the perspectives of a primary care physician (PCP) examining the problem at threelevels: global health policy, quality process improvement, and more intimate clinical caring. It posits thatED overcrowding is actually a symptom of 10 more fundamental problems in U.S. health care and EDs:variations ⁄ supply-demand mismatch; primary care provider shortfalls; limited after-hours access; admis-sion throughput challenges; clinical challenges related to discontinuity patients; clinical challengesrelated to those with special needs; interruptions; testing logistical challenges; suboptimal informationsystems; and fragmented ⁄ dysfunctional health insurance system, leaving many un- and underinsured.

ACADEMIC EMERGENCY MEDICINE 2011; 18:1255–1261 ª 2011 by the Society for AcademicEmergency Medicine

T his conference permits us to step back from thedaily frenzy and frustrations of caring for patientsin overcrowded emergency departments (EDs) to

think more broadly about causes and approaches foraddressing the growing problem of overcrowding.1

While not an emergency physician (EP), I spent many -hours working in the emergency room at Cook CountyHospital (and its overflow area for less urgent patients)

as a trainee and junior attending. We liked to say thatCounty’s ER (the real ER, on which the famous TV seriesis based), like everything at County, is so far behind …it’s ahead. And indeed we were decades ahead of thenational crisis in nearly always being overcrowded, lar-gely as we are seeing today, as a result of backup frominpatient overcrowding. Adding insult to injury, privatehospitals in Chicago liberally sent us patients, at timesunstable patients, often claiming their ‘‘beds were full,’’when in fact the patient had an original diagnosis ofAIDS (AIDS—acute insurance deficiency syndrome). Ourstudies2,3 on these problems at County in the 1980s led tothe passage of EMTALA, which stemmed some of theworst abuses, but obviously did little to fix the underlyingproblems.4

One of the special privileges of working at a placelike Cook County was the fact that we were face to facewith larger policy and social forces every day. County’sgift was giving us a zoom lens, teaching and forcing usto telescope between the macro and micro views. I willborrow this zoom lens, moving back and forth, in andout, between three vantage points: more global healthpolicy perspectives, the midrange views afforded byquality process improvement, and the intimacy of theclose clinical attachment related to deeply caring forour patients.

While the crisis of ‘‘overcrowding’’ is the chief com-plaint that brought us together for this consensus con-ference, we know that this is really a symptom ofdeeper problems. I will touch on 10 of these (Table 1).These problems seem both simultaneously overwhelm-ingly insoluble and loaded with opportunities to make

ª 2011 by the Society for Academic Emergency Medicine ISSN 1069-6563doi: 10.1111/j.1553-2712.2011.01225.x PII ISSN 1069-6563583 1255

From the Brigham and Women’s Hospital Center for PatientSafety Research and Practice, Division of General Medi-cine ⁄ Primary Care Brigham and Women’s Hospital, HarvardMedical School, Boston, MA.Received July 20, 2011; revision received August 23, 2011;accepted August 23, 2011.This manuscript represents a component of the 2011 AcademicEmergency Medicine Consensus Conference entitled ‘‘Interven-tions to Assure Quality in the Crowded Emergency Department(ED)’’ held in Boston, MA.Funding for this conference was made possible (in part) by1R13HS020139-01 from the Agency for Healthcare Researchand Quality (AHRQ). The views expressed in written conferencematerials or publications and by speakers and moderators donot necessarily reflect the official policies of the Department ofHealth and Human Services, nor does mention of trade names,commercial practices, or organizations imply endorsement bythe U.S. Government. This issue of Academic Emergency Medi-cine is funded by the Robert Wood Johnson Foundation.The authors have no potential conflicts of interest to disclose.Supervising Editor: James Miner, MD.Address for correspondence and reprints: Gordon Schiff, MD;e-mail: [email protected].

concrete, meaningful incremental improvements thatcan make a difference and perhaps even help catalyzelarger change. As I zoom in and out, hopefully a widerbut also more closeup view of these problems canemerge.

Doing full justice to this daunting list is not possi-ble; rather I will focus on a half-dozen high leverageareas for improvement. These include designingmore robust follow-up ⁄ feedback safety nets; the needfor a new science of ‘‘uncertainty safety’’ as part ofrethinking diagnosis reliability in the ED; streamliningand strengthening electronic medical record (EMR)clinical documentation functionality to increase qualityto support cognition, decision-making to offset infor-mation overload, and improve production efficiencies;enhancing the ED-imaging interface and higher-levelcollaboration with primary care physicians (PCPs);and finally engineering ‘‘pull systems’’ for admissions ⁄discharges.

WHAT IS CAUSING ED OVERCROWDING?

While popular stereotypes blame frivolous overuse andhordes of uninsured patients, the organizers of theconference wisely and categorically dismiss these vic-tim-blaming prejudiced and scientifically inaccurateexplanations in the proposal for this conference:

The causes of crowding are multifactorial. There isa widespread misconception among the public,policymakers, and the lay press that crowding isprimarily caused by large influxes of patient arriv-als to the ED, particularly among the uninsuredand ⁄ or the poor. However, studies conducted overthe past decade have consistently found that thestrongest predictor of crowding is inpatient bedavailability.

As a small reality test, I did a quick poll of several EDcolleagues in the United States and Canada. There wasremarkable consistency. Despite some predictable vari-ations (e.g., public hospital had a bigger problem with alack of primary care), overall this quick snapshot usingthe widely used three-component conceptual model(input, throughput, output), supplemented by my ownsubcategories, reinforced the sense that bed availabilitywas the largest driver of the problem, with multipleother contributors playing smaller but definite roles(Table 2).

As is reflected by these admittedly subjective weigh-tings by a range of experienced EPs, inappropriateoveruse comprises perhaps 5% of the problem. Thisnumber closely matches the Centers for Disease Con-trol and Prevention estimate that only 8% of ED visitsare for a nonurgent problem.1 Further, from thepatients’ vantage point it is difficult to fault sick peoplefor exercising what they perceive as their best optionsbased on their fears, knowledge, and other ‘‘patient-centered’’ choices.

WHO CAN TELL IF AN ED VISIT IS APPROPRIATE?

An example Dr. Pat Crosskerry offers is a subconjuncti-val hemorrhage, which physicians know is generallyquite benign and hardly a life-threatening emergency,but for a patient can be extremely frightening—howdoes the patient know that he or she is not (as one ofhis patients worried) ‘‘bleeding his or her brains out.’’Likewise, I will relate a personal story, similar to what Isuspect each of us could also share from personal,family, or professional encounters.

As a third-year medical student, about to start mymedicine clerkship, I experienced sudden onset of chestpain radiating down my left arm associated with short-ness of breath and an indescribable but powerful feel-ing of impending doom. I went to the ED convinced Iwas experiencing a near-fatal heart attack. The EPswere not only unimpressed that I had an acute MI, butreadily dismissed me, with a diagnosis of ‘‘medical stu-dent anxiety syndrome.’’ A few days later, still havingnagging left-sided chest pain and dyspnea, I begannoticing a grade 6 ⁄ 6 heart murmur (could hear acrossroom without a stethoscope). My roommate, who hadcompleted his medicine clerkship, diagnosed acute peri-carditis—yet another misdiagnosis. Finally, several dayslater I was able to see my PCP who immediately recog-nized my Hammans sign and evidence of mediastinalemphysema and ordered the chest x-ray that showed a40% pneumothorax.

Five years later, now a medical chief resident, I expe-rienced what I thought was an acute recurrence basedon very similar symptoms, reinforced by my nowbroader medical knowledge that spontaneous pneumo-thorax frequently recurred.5 Thus, I presented to theED to obtain a chest x-ray. Much to my surprise, it wasnormal. Blue Cross denied reimbursement for the visit,since there were (in their post hoc review) no findings

Table 1Overcrowding: Chief Complaint—or Symptoms of Deeper Problems

1. Peak and valley variations, but mostly in overloaded state.2. Shortfalls of primary care to capacity ⁄ ability to intercept ⁄ decrease demand, as well as take handoffs from ED.3. After-hours access to primary care.4. Admission throughput—full beds leading to ED boarding.5. Clinical challenges assessing ‘‘unknown’’ patients.6. Special population challenges: mentally ill, homeless, substance dependent, oncology, cardiology, complex medical

patients.7. Frequent and major interruptions and distractions.8. Testing logistics ⁄ issues: delays, decision-making, follow-up.9. Lack of unified, efficient information systems—for access prior history, tests, assessments, meds, easy documentation.

10. Dysfunctional health insurance system—lack of universal coverage, fragmented rather than unified system.

1256 Schiff • LEVERS FOR OVERCOMING OVERCROWDING

to justify coming to the ED. I guess they were smarterthan me about knowing what I did, or did not, have.

Another 5 years after that, now an experienced inter-nal medicine attending physician, I was mowing ourtiny lawn and experienced a vague twinge of chestpain. After ignoring and dismissing the pain for8 hours, my wife convinced me to go to the ED. Sureenough, I had a 20% pneumothorax. Thus, my battingaverage in ‘‘knowing’’ what was wrong with me, in pre-dicting the right diagnosis and knowing when andwhether to use the ED, was pretty close to zero. Itwould be hard to have a more ‘‘informed’’ consumer asa patient than me, yet my decision-making related towhat was wrong with me and when I should go to theED showed that I was pretty ignorant, at least inretrospect.

FINANCIAL BARRIERS THE ANSWERTO OVERCROWDING?

Whether imposing a high copayment or having to paythe full bill (as part of a high-deductible health insur-ance plan) would have sharpened my clinical acumenin deciding whether to seek or avoid coming to theED for my pneumothorax is questionable. Unfortu-nately, much of health policy aimed at holding downcosts is based on such questionable logic. As the eco-nomic recession continues to grow, so are the painfuleconomic consequences (including bankruptcy, homeforeclosure, and diverting money from putting food onthe table) of accessing medical care. We see storiessuch as the one on page 1 of the New York Times last

month with the headline ‘‘Health Insurers MakingRecord Profits as Many Postpone Care.’’6 Hopefully weare not heading in the direction of the paradox memo-rialized in an essay by the poet Eduardo Galeano.‘‘The World Bank praises the privatization of publichealth in Zambia.’’ It is a model for the rest of Africa.There are no more waiting lines at hospitals. ‘‘TheZambian Post Daily completes the idea: There are nomore waiting lines at hospitals because now peopledie at home.’’7

More productive (and ethical) approaches lie in delv-ing more deeply into who is actually coming to EDsand why and then seeking opportunities to put in placeeffective programs to deal with the problems drivingutilization and crowding. One study to better under-stand where such improvement opportunities existed,performed at my current hospital (Boston’s Brighamand Women’s), analyzed the diagnoses for the loweracuity patients (note: low acuity is not synonymous withnonacute). It identified thousands of annual visits forconditions such as back pain, sprains, pharyngitis, skinrash, dental problems, and mild respiratory illness. Nodoubt many of these visits could have been treated byPCPs, particularly if they provided urgent care accessand services. This finding correlates with data showingthat ED visits decreased as the proportion of physicians(in a metropolitan area) increased.8 More interestingwas the finding from the Brigham group that a muchlarger opportunity (in terms of numbers of visits)existed in developing special care programs for mentalhealth and substance abuse patients, most of whose vis-its were not triaged as being low acuity.

Table 2ED Overcrowding: Where Do the Problem and Opportunities to Improve Lie?

Min Max

Upstream 18No PCP 4 1 10Lack after-hours access from usual source care 3 1 6Could be safely handled nonemergency by PCP 4 1 8Inappropriate patient utilization choices 1 0 2Chronic mental illness, substance abuse, homelessness 4 2 9Seasonal ⁄ surge demands 2 1 4

Intra-ED Flow 20Increased volume numbers patients 2 1 3Inadequate space for demand ⁄ census 2 1 4Insufficient staffing for volume ⁄ peaks 2 1 5Throughput efficiencies for radiology 2 0 5Throughput efficiencies for lab tests 2 0 5Clinical documentation, other EMR inefficiencies 1 0 3Language barrier interpreter services delays 1 0 2Delays related to specialist ⁄ consultations 2 1 6Observation unit issues: space, staff, policies 1 0 2Other ⁄ general workflow inefficiencies 4 1 7

Downstream 63Inpatient bed unavailability for required admissions 35 19 58Lack mechanisms for ‘‘safe’’ follow-up checking (nurses phoning) 7 3 12Lack mechanisms for ‘‘safe’’ early discharge pending labs 4 3 5PCP not readily available to ‘‘pull’’ for follow-up 10 2 15Social service resources, discharge option 7 2 13

All values reported are percentages.EMR = electronic medical record; PCP = primary care physician.*Focus group ⁄ poll of 10 selected EPs in U.S. in Canada.

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INTRA-ED FLOODING: FLOW AND EFFICIENCIES

Recent news filled with memorable images of therecord flooding of the Mississippi River conjures up aparallel metaphor of ED flooding. Thinking aboutdecreasing upstream demands, intra-ED flow and effi-ciencies, and downstream flow blockages brings us tothe next set of questions regarding what EDs might dointernally to buffer the upstream and downstream fac-tors that seem out of their direct control. Thus manyEDs have worked on throughput efficiencies forimproving their processes for assessing, testing, andreadying patients for discharge. Acknowledging thatEDs have been working a variety of fronts to look forimprovement opportunities, here I wish to touch onseveral emerging, relatively untapped promising leveragepoints.

Radiology use in the ED is one levee that is overflow-ing. Over the past decade, use of CT scans alone hasincreased fourfold (from 2.8% to 13.9% of all ED vis-its).9 Putting aside serious concerns about cost andradiation exposure, there are a host of areas forimprovement for processes improvement, particularlyin the interface between the ordering clinicians and theradiology department. As outlined by Jones andCrock10 (Australian radiology and ED physicians whohave collaborated on a number of projects), there arenumerous areas where an enhanced interface betweenthese two departments—their staff, their handoffs, jointgrappling with the clinical question—could be substan-tially improved (Table 3). Each of these areas representsrecognized and often unrecognized speed bumps incaring for patients that ultimately contribute to EDcrowding by creating rework, friction, delays, andmisdiagnoses.

FACILITATING DIAGNOSIS

Many of us working in the area of diagnosis error andimprovement believe that conceptualizing a ‘‘diagnostictime out’’ (like a preprocedure time out) could be help-ful in better choosing, performing, and interpretingtests. Questions such as when should we have suchtime outs (after all, we want to speed, not arrest

throughput) are paramount. But there is often a need tostop and ask questions such as are we sure this imag-ing test is needed (will it influence my treatment); is thisthe right test for the clinical question; what pitfalls(false negatives ⁄ positives) and safety issues need to beconsidered; what else are we overlooking; is theresomething about the results that does not fit withthe clinical picture; and do the radiologists andthe clinicians understand each other’s findings and dothe conclusions align?10

Because diagnosis is so central to the role of the ED,other diagnosis issues also warrant attention. One, thesubject of a session at the 2010 Diagnosis Error in Med-icine Conference in Toronto, centers around the ques-tion of the calibration of accuracy vs. confidence.Research from psychology shows that there is a discon-nect between accuracy and confidence.11 Those whoseaccuracy is poorer, and situations where the accuracyof decisions is lower, unfortunately are not those wherethe confidence is least. Ideally this relationship shouldbe perfectly calibrated, so that when we are more cer-tain, we are more often right about what is wrong withthe patient and vice versa. This is particularly importantin the ED, where there is so much uncertainty as wellas danger from being wrong. It is not just a matter ofbeing overly confident (i.e., arrogantly dismissing apatient or complaint as nonserious when in fact it is aharbinger of an overlooked serious diagnosis). Inappro-priate underconfidence can also be a big problem in theED, as physicians lacking appropriate confidence (over-all, or in a particular case) can be paralyzed, delayingmore rapid throughput and ⁄ or ordering excessivetesting and observation.

What is needed is not just a more accurately cali-brated linear confidence scale, but richer approaches todealing with ubiquitous uncertainties omnipresent inthe practice of EM. We need to create a more advancedscience of ‘‘uncertainty safety.’’ One element is the needto place safety nets under our diagnoses, so we can (inmany cases) safely send patients home even whenuncertain about exactly what is wrong.12,13 I find itamazing that most EDs lack a systematic method forautomatically following up discharged patients toensure that they are improving as expected. With newtechnology such as interactive voice response (IVR),calling patients to do this should be relatively easy. Wehave been piloting using IVR calls post–acute care visitsin three clinics in an AHRQ-funded project at the Uni-versity of Alabama, as well as following up patientsstarted on new medications here in our primary careclinics at Brigham and Women’s clinics.14

ENHANCING USEFULNESS AND PRODUCTIONEFFICIENCY OF EMR

Harvard physicians (mostly non-EPs) were recently sur-veyed by CRICO ⁄ RMF (Cambridge, MA; their malprac-tice insurer), on their views of their EMR. Despiteworking with what is considered to be one of the lead-ing, state-of-the-art, clinician-built systems, their frus-trations and desires for improvements were evident.Leading their wish lists: 65% wished for better ways toidentify outstanding patient issues, 61% wanted easier

Table 3Areas for Improvement ED—Radiology Interface

Unnecessary imaging test requested leading to potentialdelayed diagnosis condition not requiring imaging

Wrong imaging test requested unable to answer the clinicalquestion

Wrong patient or wrong body part imagedTest not performed in a timely fashion resulting in delayeddiagnosis

Test performed incorrectlyInadequate image qualityImaging test not interpreted in a timely fashionInterpretation ⁄ reporting error by radiology (or ED) failures inperception, data gathering, synthesis

Error in timely transmission or receipt of reportReport not understood, synthesized, acted on by receiver

Modified from Jones and Crock.10


ways to enter information at the point of care, 60%sought better ways to recognize patients clinical prob-lems, and 57% wished for improved access to otherinformation sources at the point of care.15 Worse yet,our Brigham ED resident physicians are currently stilldocumenting on paper (residents write paper notes andattendings dictate a note that is often not in the com-puter when I try to find out what has happened to mypatients 1 or 2 days later). As EDs around the countrybecome more fully computerized, we must addressquestions about quality and efficiency.

According to a seminal report released last year bythe National Academy of Science, entitled Computa-tional Technology for Effective Health Care: ImmediateSteps and Strategic Directions, ‘‘clinicians spend a greatdeal of time and energy searching and sifting throughraw data about patients and trying to integrate thesedata, with their general medical knowledge to formmental abstractions and associations relevant to thepatient’s situation. Such sifting efforts force cliniciansto devote precious cognitive resources to the details ofdata and make it more likely that they will overlooksome important higher-order consideration.’’16 Thesewords perfectly describe many millions of wasted hoursin our nation’s EDs. Missing information about apatient’s past history, medications, and tests is

ubiquitous. Seemingly paradoxical is the opposite prob-lem of information overload. It is increasingly impossi-ble for EPs to review all available online documentsand data. Finding the needle of desired information inthe haystack of computerized scanned, dictated, poorlyorganized template notes and scattered lab reports isdestined to surpass unavailable information as themajor problem. One could say that needed informationhas gone from being ‘‘missing’’ to ‘‘hiding’’ or at leastcertainly not instantly available in the format neededfor quick access and review.

If we are looking for better ways to support andstreamline diagnosis in the ED, reengineering EMRsand clinical documentation is critical. We recently pub-lished a discussion of 15 ways EMR systems should beredesigned to support diagnosis workflow.17 Table 4 isa modified version as it applies to the ED setting.

Beyond reengineering internal ED workflow and doc-umentation, the EMR needs to be deployed to facilitatecommunication and handoffs particularly to the PCP.Here again, the pioneering system at Brigham is both amodel and an illustration of wished-for features to trulymake this work effectively and efficiently. Figure 1 illus-trates a wonderful system we have in place whereby Iam automatically notified each time one of my patientscomes to the ED. Upon discharge, an e-mail such as the

Table 4Goals and Features of Redesigned EHR Systems to Support ED Diagnosis and Workflow

Role for ElectronicDocumentation Goals and Features

Providing access toinformation

Ensure ease, speed, selectivity, filtering information searches; to aid cognition throughaggregation, trending, contextual relevance, and minimizing of superfluous data.

Recording and sharingassessments

Provide a space for recording thoughtful, succinct assessments, differential diagnoses,contingencies, unanswered questions; facilitate sharing and review of assessments by bothpatient and other clinicians.

Maintaining dynamicpatient history

Carry forward information for recall, avoiding repetitive patient querying and recording whileminimizing erroneous copying and pasting.

Integrating ⁄ maintainingproblem lists

Ensure that problem lists are integrated into workflow and facilitate continuous updating.

Tracking medications Record of medications patient actually taking, patient responses to medications and adverseeffects to avert misdiagnoses and ensure timely recognition of medication problems.

Tracking tests Integrate management of diagnostic test results into workflow to facilitate appropriate ordering,review, assessment, action, handoffs, and documentation.

Ensuring coordinationand reliable handoffs

Aggregate ⁄ integrate data from acute and chronic care episode encounters into quicksnapshot ⁄ synthesis from prior, to subsequent providers.

Safety need for patientfollow-up

Facilitate patient education about potential red-flag symptoms to watch for; track follow-up.

Providing feedback Automatic provision of feedback to upstream clinicians (including recent EP from recent visits),facilitating learning from outcomes of diagnostic decisions.

Providing prompts Provide checklists to minimize reliance on memory and directed questioning to aid in diagnosticthoroughness and problem solving.

Buffering interruptionsproviding placeholderfor resumption of work

Delineate clearly in the record where clinician should resume work after interruption, preventinglapses in data collection and thought process.

Calculating Bayesianprobabilities

Embed calculator into notes to reduce errors and minimize biases in subjective estimation ofdiagnostic probabilities.

Providing access toinformation sources

Provide instant access to knowledge resources through context-specific ‘‘infobuttons’’ triggeredby keywords in notes that link user to relevant textbooks and guidelines.

Real-time consultations Integrate immediate online or telephone access to consultants to answer questions related toreferral triage, testing strategies, or definitive diagnostic assessments.

Increasing efficiency The holy grail. Can more thoughtful design, workflow integration, easing and distribution ofdocumentation burden speed up charting, workflow, thereby freeing time for communicationand cognition?

Modified from Schiff and Bates.17


one illustrated is generated. While I value such notifica-tion, think about my workflow. I would like to pick upthe phone to call the patient to discuss how he or shewas doing and arrange any needed follow-up. Ideally, Iwould want to review the ED note in real time as Italked to the patient to intelligently review the findings,assessment, ED course, and discharge plan. However,this notification lacks the patient’s contact information(why couldn’t they have included the patient’s phonealong with the discharge diagnosis?), so I have to openour EMR and find the patient (no hot link), which takesseveral minutes. While I can usually manually look upand find the phone number, there is generally no EDnote to be found (as mentioned above, resident note ison paper, attending is a delayed dictated note). I sus-pect manual systems that fax the ED note to the PCP,which exist in some community hospital settings, prob-ably do a better job than we do with our powerful ITsystem.

DISIMPACTING DOWNSTREAM BLOCKAGES

There is a strong consensus that the factor making thegreatest contribution to ED overcrowding is obstructedthroughput to inpatient admissions. In preparing thispresentation on ED overcrowding, I wondered whatexpertise I, as a non-EP, have to speak on this topic.Also, I was busy because my time to prepare this talkcoincided with a 2-week block as an inpatient attend-ing. So I not only lacked expertise but also time to pre-pare. Then it dawned on me that the problem is me, orat least my inpatient service—not dischargingpatients in a timely enough way to open beds for newadmissions.

I often joked during my 35 years working with theED at Cook County that treating ED overcrowding byexpanding the number of beds in the ED is like tryingto treat a bowel obstruction by stretching the mouth!Clearly we need to disimpact things at the other end.Thus, I looked at my logs for the 17 days on inpatient

service and counted the number of bed days needlesslylost to bed-blocking patient situations. Out of a total of106 patient bed-days on my service, 21 were purely forpatients awaiting placement, and another eight wereoccupied by patients awaiting delayed procedures.Thus, a total 29 of 106 or 27.4% of the bed-days were,by my conservative estimates, unnecessarily unavailableto ED admissions. One particularly frustrating patientsituation was a woman admitted for severe hypoglyce-mia resulting from a suicide attempt with insulin. Oncemedically stable, she clearly needed discharge to a facil-ity that had psychiatric services. But she also had multi-ple medical problems (ENT cancer requiring enteralfeeding, alcoholic cirrhosis). No medical facility wouldtake her because of the psychiatry issues. And no psy-chiatric facility would admit her because of her medicalissues. At first I thought this was impossible, that theremust be one skilled nursing bed somewhere in the cityof Boston for this unfortunate woman. I struggled,working with the psychiatry attending and the dis-charge planning nurses, for nearly the entire 2 weeks.When I handed off the service to the new attending,she was still there.

There is a profound concept in Japanese ⁄ Lean qual-ity theory that I have only barely begun to grasp—thepower of ‘‘pull’’ systems.18 When it comes to admis-sions, we have a ‘‘push’’ system. Instead of an emptybed smoothly pulling a patient from the ED into it, wehave a system where the ED has to push to find ⁄ makea bed for a needed admission. Rather than smoothcontinuous flow, we have batching and backing up ofboarded patients in hallways and overflow areas.Rather than frictionless flow, we have the wastedenergy from the friction and hassle of fighting to tryto free up a bed. Some might argue that empty bedswould provoke supply-induced demand and lead tounnecessary admissions lubricated by available beds.While this requires a longer discussion and moreempiric data, the reflex to govern utilization appropri-ateness by creating barriers, borders, and backup of

Figure 1. System in place whereby I am automatically notified each time one of my patients comes to the ED.


ED beds needed for acutely ill patients, strikes me(and I suspect most of us here today) as a misguidedand wasteful (not to mention unsafe) approach. Ratherthan a well-calibrated balance of supply and demand,and a sound set of guidelines and criteria for admis-sion, we are turning EDs into wrestling rings andunsafe venues.

Finally, and again the problem points back to me, isthat question of how we PCPs, along with and othercomponents of the ambulatory health care system, canhelp expedite discharges from the ED? A well-functioningpull system has barely been imagined, let alone imple-mented for such throughput. In my view it would beone based on every patient having a well-supportedand continuous PCP relationship (something that isbeing undermined as we speak by insurers who aretelling my patients they can no longer continue gettingcare from physicians like me at academic centers with-out steep financial penalties), skillful teams who quicklyembrace the most complex medical and psychosocialpatients and problems, instant 24 ⁄ 7 access (phone,Internet) to me and others who intimately know thepatient, and a host of supports to sustain my ability toplay this role. Patient-centered medical home initiativestilt in this direction, but if they are to be more than justpay-for-performance style-point scorecards, or emptyshells propping up the status quo, there needs to bemuch more support for meaningful relationships withpatients and smooth, supported pull systems. It is thisgoal and vision to better care for the patients by work-ing smarter and better with each other that will restorejoy and efficiencies in our overcrowding EDs.

The author acknowledges Karen Cosby, Pat Crosskerry, CandaceMcNaughton, Steven Russ, Jeff Schaider, Wesley Self, CoreySlovis, and Jay Schuur for sharing their views on causes of EDovercrowding (contributing to Table 2).

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system dynamics and dysfunctionalities: levers for overcoming emergency department overcrowding

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