Emergency Department Overcrowding: Right diagnosis, wrong etiology, no treatment
There’s been a lot of hoopla about the phenomenon of emergency department overcrowding in recent
years. This has been an issue worthy of Time magazine, CNN, and Nightline. Do we know the solutions?
Are we on message? Or have we done ourselves harm?
Emergency departments are overcrowded because of the large number of patients seen in the ED who
could better be seen elsewhere.
Wrong! Count the times you left work thinking “Gee, if only those acne cases hadn’t come in, it would
have been an easy day.” Sore throats are not what grind our system to a halt. Admissions are. Admissions
fill our examining rooms, and fill our hallways. Treatment of heart attacks is not delayed because of sore
throats. Treatment of sore throats is delayed because of patients with heart attacks, who may “enjoy” a
substantial portion of their hospitalization in our hallways. Any delay in the treatment of the next heart
attack entering the emergency department is due almost solely to the previous heart attacks, pneumonias,
and traumas already admitted, but still remaining in the emergency department and consuming staff time,
space, and resources.
The narcotizing notion that overcrowding is caused by sore throats and the flu suggests that the problem is
temporary, and that the problem is not a hospital problem. The popular issue of the “unnecessary” ED visit
has so overtaken the ED as a topic of discussion that one forgets that we actually see sick patients. It is an
issue seized by the legislature and all the insurers of the land, both of whom know that one guy from
Kansas who was on his tractor when an airplane crashed into him represents the only appropriate visit to
the nation’s emergency departments in 1999.
Thank God for the TV show, “ER.” At least they get it right – the patients are sick, and the personal lives of
the staff are a mess. The next ED physician who walks to the podium to talk about overcrowding caused
by the healthy happy masses looking for a good time in the emergency department should get a nice little
curare dart in the deltoid. We see sick patients and make people’s lives better, and we’ve made a big damn
mess of letting people know that.
When the emergency department is truly overloaded and cannot provide care to further patients, the
hospital can divert ambulances to other area hospitals.
Wrong! If our emergency department is full, so are the other area emergency departments. In some areas,
there IS no other emergency department for miles. In some regions, entire hospital systems run at over
100% occupancy for months on end. If you’re full and they’re empty down the street, they must have a
pretty scary ED.
When the emergency department is truly overloaded and cannot provide care to further patients, the
hospital can transfer patients to other area hospitals.
Wrong! As noted above, entire regions can be overloaded with patients. The act of attempting to transfer a
patient, should the patient agree to transfer, can literally consume hours of staff time in phone calls and
paper work needed to arrange for the transfer of a patient to another facility. A nice swig of Ipecac is more
palatable. An ED full of admitted patients is already out of control, pushing staff beyond their capacity to
provide adequate care. In such circumstances, one can ill afford the time required to arrange for transfer.
When the emergency department is truly overloaded with admitted patients, the hospital should call in
additional staff to provide care for these patients.
Wrong! A substantial number of emergency departments cannot fill positions needed for routine staffing
of the emergency department, much less call in additional staff. In most places, additional staff simply
does not exist. This sort of policy is another one of the “we tried we failed” policies which allows someone
to show they really care. Of course, the proper staff to call in for admitted patients would be in-patient
nurses and in-patient physicians, not additional ED staff. If you enjoy funny and contorted expressions on
people’s faces, and want to test your job security at the same time, suggest that at your next medical board
meeting.
When the emergency department is overcrowded with admitted patients, elective admissions should be
canceled, and elective surgery should be rescheduled.
Wrong! First, the era of “elective admission” is no more. Patients get admitted to the hospital because they
are acutely ill. Minor surgery has moved to the ambulatory setting. Also, the patient with the “elective”
cholecystectomy has committed to detailed arrangements with work and family prior to undergoing the
procedure. The “elective” surgery or procedure, such as cardiac catheterization, not performed today
becomes the “emergency” procedure of tomorrow. In some regions where hospital occupancy runs
chronically at 100%, following this rule would simply eliminate all elective procedures on a permanent
basis. Since most patients admitted to a hospital are medical patients, this also allows the department of
medicine to shut down the department of surgery. Thus, the best way to implement this policy is simply to
declare that all surgery is emergent. In fact, admit them to a hallway bed in the emergency department.
Admitted patients held in the emergency department cannot be moved to the inpatient service until a bed is
available.
Wrong! There’s far more square footage and hallway space on the in-patient units than in the ED. Don’t
like the hallways? – Use conference rooms, waiting rooms, sunrooms. Put the patients on the wards where
the appropriate nurses and physicians providing in-patient care exist. Spread out the overcrowding
problem. Let multiple units absorb a small part of the larger crisis. If the patient is to be stuck in a hallway
for lack of beds, why should they care which hallway they’re stuck in? Who doesn’t believe that beds
would be found quicker for these patients if they were moved onto the units? Every objection to placing
patients in hallways on floors pending a bed also applies, in spades, to the ED.
Can’t do it? There is no JCAHO policy that gives the ED hallway special status. We’re not Stonehenge.
Bring in you local structural engineer to demonstrate the surprisingly observable fact that the ED is not
built out of rubber bands that can infinitely stretch to provide never-ending space. They might also be able
to point out the similar amenities available in any hallway, regardless of location.
If your hospital has a full-fledged OB department, take your administrators on a tour of the OB ward, that
“other” area of the hospital with the magic rubber-band hallways. Ever hear of an OB department that
refuses a woman at the door in labor because of lack of space? Ever hear of an OB department calling the
ED to let them know that the OB ward is taking a “time out”, and for the ED to play obstetrician for a
while? Ever hear the OB chief suggest that you keep the woman in the ED and let her deliver in the
hallway? (I have no doubt that someone reading this probably has had this experience, but I think the
exception proves the rule.)
Of course, one could always find more available beds if only change-of-shift came more often.
Admitted patients should receive the same standard of care, regardless of their location in the hospital.
Wrong! How many times have you held your fifth or sixth ICU patient in the ED (without additional staff,
of course) when the ICU won’t take a patient because it would mess up their “staffing ratios”? Where is
the in-patient physician specialist? I mean, sure, we’re good. But who wants to pretend that we are the
equal of the specialist in providing specialty care to in-patients (assuming, of course, that we had the time
to stop and do so)? Where is the in-patient nurse specialist? Where is the warm food and the discharge
planner?
The worst perversion of this requirement is forcing the already overtaxed ED nurse to complete a 10-page
comprehensive admission form on all patients admitted but held in the ED. This has four measurable
effects. First, the ED nurse is pulled away from providing real care to emergent patients, and is instead
completing mind-numbing admission forms. Second, the in-patient unit, which now will not have to
complete the form, is rewarded for whatever delays they have contributed to the obstruction to moving the
patient to the in-patient unit. Third, the primary nursing provider on the in-patient unit never has to really
get to know the patient, since the ED already does all the paperwork. Fourth, the patient doesn’t benefit
from this – not even a tiny bit.
Currently, the only way to truly implement this policy during ED overcrowding is to move all of the inpatients out of their rooms into the hallways and have their treatment rendered by someone other than their
personal physician. Now you have a uniform standard of care.
The hospital should have a policy to facilitate early discharge in circumstances where the emergency
department is holding admitted patients.
Wrong! Well, they may have a policy. But a well-run hospital is going to have early discharges anyway.
Of course, “early” can be interpreted as “shortly after the afternoon change of shift”. What incentive is
there for the in-patient staff and admitting physician to disrupt THEIR day when the emergency
department can so easily bunk patients in the emergency department? Why spread the “mess” to other
areas, when it’s so nicely contained in the emergency department? All the more patients to fill out those
patient satisfaction surveys!
Sudden and unusual ED overcrowding gets everybody’s attention. But when it’s a day-to-day
phenomenon, “disaster fatigue” sets in, and it becomes simply business as usual. Others don’t care, not
because they’re uncaring, but because, as long as patients can be held in the ED, it’s just not their problem.
This reflects institutional culture, not individual preference. I don’t involve myself in the problems of the
operating room, or whether or not warm food is delivered to the OB suite. Why? Because it’s not my
problem. Why does OB take any woman who presents in labor? Because they believe that this is their
patient, and it is their problem. Unless admitted patients are delivered to the floors, bed or no, the problem
will remain ours.
Of course, this doesn’t preclude meetings to discuss the problem, get the data, look into different options,
and have further meetings. That’s why the “C” in CQI stands for “continuous” and not “completed.”
We should quit discussing solutions that don’t work, because they impede the implementation of solutions
that CAN work.
Well, of course! The solution to ED overcrowding is to get rid of the crowd. Admit them and put them on
an in-patient unit. Get JCAHO to mandate it. Clearly, nothing else has, will, or can work.