Emergency room overcrowding: causes, impacts, and solutions

Emergency Room Overcrowding

This is a template and guideline. Please do not use as a final turn-in paper.

There is little doubt that patient boarding -- holding patients in the emergency department (ED) after they are ready to be admitted to in-patient care -- is the main cause of emergency room overcrowding in hospitals in this country. An overwhelming base of knowledge and research indicates the long-held myth that indigent patients are the cause of the almost catastrophic problem of ED overcrowding is based on opinion and perception but not fact.

Actually, the increase in ED patronage is due to middle-income people who already have some source of health care. This has important repercussions for President Obama's emphasis on passing universal health care because it means that providing health insurance for everyone will not, by itself, solve the problem of overcrowding.

Many contributors to the increase in visits to EDs exist: population increases, the aging of our population, the increased numbers of time-sensitive interventions requiring state-of-the-art hospital care, larger numbers of patients with complex medical problems requiring evaluation in a setting in which sophisticated testing and consultation are available, and complications from medical and surgical treatments (Bernstein, 2008, para. 9).

There is also truth to the fact that the number of EDs in this country are shrinking at an alarming rate and that this is a contributing factor to overcrowding, but expert after expert will vouch that hospital admission procedures and the non-use of "full-capacity protocol" -- the frequent and constant co-ordination between ED and in-patient care to ensure 100% of the in-patient hospital beds are being utilized -- are, by far, the tall poles in the tent regarding fixing the overcrowding situation. It is the lack of effective use of full-capacity protocol that most demands attention and implementation to alleviate patient boarding.

The Myriad Problems

About 100 million patients visit EDs every year to receive some form of emergency care.

In 1958, a study forecast the necessity of building new emergency facilities. Since that study, ED visits have increased 650%. The number of additional emergency facilities has not kept pace. We made it clear that no one factor caused this overcrowding. It is the result of a long list of complicated legislative, social, and financial factors (Committee on Pediatric Emergency Medicine, 2004, p.878).

According to the American Hospital Association, there were 1.36 million inpatient beds in 6933 hospitals in 1981, 927,000 staffed beds in 5370 hospitals in 1991, and 829-000 beds in 4956 hospitals in 1999 (American Hospital Association, 1999).

In Texas, some hospitals have seen ER volumes increase by 2.5% in the last 12 months. "That's 70,000 visits a year in our two facilities," says Art Chance, VP of Operations at East Texas Medical Center. Things are so bad there that they are warning patients who really don't need emergency care to go elsewhere for treatment (Chance, 2009).

To place this enormous problem in perspective, we must also understand that this is not just a U.S. problem but a world-wide emergency that needs to be addressed. Note what the Australiasian College of Emergency Physicians suggests as the solution to the problem:

"Overcrowding in the nation's emergency departments is killing 1,500 people a year, according to the Australasian College of Emergency Physicians. Recent research suggests that these avoidable deaths occur because there just are not enough beds in the rest of the hospital system to take emergency patients once they need more specialized, longer term care" (Epstein, 2009, para. 1).

In the U.S., trained emergency physicians are in short supply. And the backbone of every ED -- well-trained emergency-care registered nurses -- are in critical shortage. In some states, the vacancy rate of these RNs is 30%. As a result, EDs and hospitals are forced to cut back on services.

Enormous increases in liability insurance premiums are also a culprit. Increases in some states for certain sub-specialists can reach 25-50% annually. The problem here is that physicians that specialize in ED work pay more for insurance than others. Many decide that ED service is just not worth the cost or the liability.

Patients who need emergency care are backed up to the point that loss of life occurs in some cases. Dr. Robert Rosenbloom, President of the California Chapter of the American College of Emergency Physicians says this: "Long waits mean patients don't get the treatment they need when they need it. We have had to resuscitate patients in waiting rooms and hallways because the ER is full" (Gozzo, 2009, para. 4)

Linda Laurence, president of the American College of Emergency Physicians:

"Assumptions that uninsured patients make use of EDs for non-emergency care have been a huge barrier in efforts to reform emergency care. The reason for emergency department overcrowding is the practice of inpatient boarding" (GetInsideHealth, 2008, para. 5).

Solutions Offerred

Many hospitals are using their own creativity to resort to on-the-spot procedures to make processes more efficient. Quick registration, bedside registration, standing orders for certain emergencies instead of having to seek out a doctor and obtain sign-off, and the use of fast-track and sub-waiting areas are all being utilized at EDs across the nation.

But for many, these are temporary and there is no more to be done -- and patients still wait.

For a time, hospitals placed some hope that retail health clinics like Emergi-Care and Minute Clinic could alleviate some of the load. But studies have found that 95% of patients utilizing such clinics would have otherwise sought care at a physician's office or other clinic, and not at an ED (Bachenheimer, 2008).

A complete "re-engineering" of current systems to allow for minimal waiting and transport to a clean available bed on an inpatient floor is the solution, many experts agree. Implementation is complicated, expensive, and not guaranteed but includes the following: (Bachenheimer, 2008)

Greatly simplify the hospital admission process.

Prioritize hospital resources for the ED. In 1996 emergency patients comprised 36% of all hospital admissions, according to the Centers for Disease Control (CDC). Today that stands at between 50% - 75%, but hospitals are not allocating the resources in a representative proportion to their "top moneymaker." Whether it is space, equipment, number of physicians and nurses, or dollars, EDs are not as well represented in hospital budgets and allocations as they should be.

Reduce non-urgent visits to emergency departments. (considered crucial to success)

Initiate "full-capacity protocol" through legislation if necessary, at all EDs.

The highly regarded Press Ganey Emergency Department Pulse Report 2009, analyzed data from about 1.4 million patient experiences in over 1,700 EDs across the U.S. For the 2009 report.

The report shows that the average ED patient spent four hours and three minutes door-to-door in ED. That is an increase of 27 minutes, over 10%, from 2002 (Press Ganey, 2009, ).

The Press Ganey Report, based on this massive amount of data, further concluded that "the best way to get patients treated and discharged from the ED is to address overcrowding in general and get the critical patients through the ED and to the appropriate floor faster" (Press Ganey, 2009, para. 4).

In June, 2009, in California, Assemblyman Ted Lieu announced a bill that will significantly lower the levels of overcrowding in California EDs. California ranks 50th of 50 states in the number of EDs; they provide only six emergency rooms to each one million patients.

Lieu's bill will implement a policy of "full capacity protocol." This will expedite the processing and flow of patients through EDs and into inpatient beds, the major problem present in California's EDs. The legislation will force hospitals and EDs to evaluate the overcrowding conditions vs. beds available in the hospital every three hours, and coordinate action to fix the blockages.

Finally, the American College of Emergency Physicians in their 2008 Task Force Report, ask and answer the question: "What Causes Crowding (in EDs)?" Their answer, unequivocally, is patient boarding -- that practice of holding admitted patients in the ED when there is no "proper" space of them in the hospital (ACEP, 2008, p. 8).

So, Let's Talk About Patient Boarding

All of the factors we have discussed above contribute to the overall crisis of overcrowding in EDs across our country. There is no question that EDs across this country are overcrowded. Yes, there are many more ED patients and fewer EDs to handle them. But the research is telling us that we could handle the overflow even with the limited resources we have, and reduce the wait times, if we could clear the treated patients faster and get them back out the door or to inpatient hospital beds. It is this shortcoming in our hospital internal processes that must be addressed. There is also no question that the mystery as to why has been solved after so many years of assumptions that have turned out to be incorrect. Study after study, and prestigious groups involved in ED practices, all agree that patient boarding is the culprit. The good news is that there a number of practical steps EDs and hospitals can take to alleviate at least some of the problem, most of which we touched on briefly. But let's look at this resolution in a bit more depth. Briefly, processes like full capacity protocols, bedside registration, bypassing triage, adding staff during increased volume, setting up a separate "line" for treating simple fractures, lacerations, etc., establishing turn-around-time (TAT) goals for procedures and patients, can go a long way to begin to cure the problem of overcrowding (ACEP, 2008, p. 10).

Full-capacity protocols. Here is a typical full-capacity protocol from Stony Brook University Hospital and Medical Center in New York:

"POLICY: When an adult patient requires admission to an Acute Care Unit from the Emergency Department and that area cannot accommodate that patient because of lack of sufficient beds, the patient will be admitted to the next most appropriate bed. In the event appropriate hospital bed utilization has been maximized, and the number of admitted patients holding in the Emergency Department has prohibited the evaluation and treatment of incoming patients to the Emergency Department

in a timely fashion, the admitted Emergency Department patients already awaiting in house acute care bed assignments will be admitted to acute care unit hall beds"

(Stony Brook Policy Review Committee, 2001, para. 4).

The one-page policy goes on to define "full-capacity" as anytime the "main" department is occupied with patients and admitted ED patients have been awaiting in-house placement for two hours. It also addresses patient priorities as to who should be placed in hall beds outside ED and what the requirements are for any department boarding patients. The precise step-by-step process to move a patient is listed and who would be in charge of the move. Finally, it spells out, in clear terms which patients cannot be considered for a move to an inpatient hallway hospital bed, and it limits the number of hallway beds -- two -- that can be utilized in any department.

As a result, Stony Brook has found that not only are patients more satisfied with their overall experience with the hospital, but that most in-hospital stays utilizing this policy of getting patients out of ED to an inpatient bed reduces the average stay by one full day. and, of course, the ultimate result of that "one less day" is that it frees more beds sooner at the in-patient departments to move more ED patients more quickly out of emergency rooms and reduces the waiting time for those not yet treated. In other words, full-capacity protocol is not just a theory -- it is working in hospitals today (Stony Brook Policy Review Committee, 2001).

Many state Departments of Health are now adopting standard policies for these protocols to be utilized when necessary rather than leaving it up to individual hospitals to come up with their own policy and procedures. New York state was the first one to do so. Other states, like California, are passing legislation to mandate it.

Improved Triage. Triage is the management of patients by the level of treatment they require. This is the first step when a patient walks in the door of an ED. A patient who has a migraine headache may have to wait for the heart attack victim. An accident victim in serious condition will take priority over a patient suffering from a gall stone. Triage establishes the priorities for any ED, and it begins the patient flow process. If done insufficiently or too slowly or by untrained personnel, it can take too much time or establish the wrong priorities. Triage also involves the use of an extensive form for evaluation which, even when done by a properly trained nurse, takes time. The ultimate problem is not only less successful treatment of patients, but more time added to patient waiting times, and an increase in the time it takes to "flow" patients through ED. In other words, it contributes to the patient boarding crisis.

"Triage bypass" is the corrective process that some hospitals are not utilizing to alleviate patient boarding situation. If a patient arrives with only a minor problem, he or she is separated and taken to an area designated as "fast track." Vital signs are then taken. If that patient is found to be more serious than first assessed, they are moved back into the ED. Since many patients fall into this category, it frees up a nurse from performing time-usurping triage and improves the flow of patient's through the entire ED. It is estimated that up to 30% of ED patients never need to get to an ED or hospital room at all (ACEP 3, 2006).

Bedside Registration. This efficient process allows a patient's charts to be available without having the patient or whoever is registering with him wait in line to register at the ED front desk. This process, though proven a time-saver in the patient flow process, does require the purchase of additional equipment such as laptop computers, patient ID card generators, and perhaps additional printers. Studies have indicated that bedside registration is an effective way to reduce the necessity for excessive patient boarding and that it can lead to an improvement in the overall length of hospital stay (ACEP 3, 2006).