Emergency Department Crowding (original) (raw)

ABSTRACT 1 Departments of Emergency Medicine and Health Policy, George Washington University, Washington 2 King Abdulaziz University, Jeddah Emergency department crowding A worldwide problem with evidence-based, but underused solutions Emergency department (ED) crowding is an increasing public health crisis in the U.S. and around the world. A burgeoning literature has found associations between ED crowding and negative outcomes, such as poor quality care, medical errors, inpatient complications, and higher mor-tality rates [1, 2]. A recent report detailed increased crowding across 16 countries, including Germany. Similar to many oth-er industrialized countries, ED visit vol-ume and crowding are both increasing in Germany [3]. Recent surveys in Germany have found increases in ED visits by 4% in 2006 and 8% in 2007, with an estimat-ed 12 million visits in 2007; however, there are no official national statistics on Ger-man ED visits [3]. Across the world, ED crowding has worsened for several reasons. First and most important, people increasing-ly chose EDs over other settings because of the convenience and the 24-7 compre-hensive care provided. In many countries, the outpatient care system makes patients wait and is poorly designed to care for acutely ill patients [4]. For these reasons, increases in ED visit volume have out-paced population growth in the U.S., Can-ada, and France [3]. EDs themselves have also become more congested as lengths of stays have increased with higher rates of laboratory testing, advanced imaging, and intravenous fluid and medication ad-ministration [5]. Particularly in the U.S., there have been dramatic increases in the use of CT scans in the ED [6]. Finally, ED crowding is worsened by ED board-ing, where admitted patients spend pro-longed periods of time in the ED before being moved to inpatient beds. Based on local reports, boarding seems to be a ma-jor theme across many countries' hospi-tals [3]. In some parts of the world, econom-ics favor higher ED crowding [7]. Be-cause caring for an acutely ill patient is much more time-and resource-intensive than a well visit, physicians increasing-ly refer their patients to the ED for work-ups. Patients also realize that comprehen-sive ED care is often superior to evalua-tion in a doctor's office for acute prob-lems. Furthermore, outpatient physi-cians increasingly are not available at off-hours when patients' acute care needs re-quire attention. For many hospitals, there are few incentives to reduce ED crowding. Having a crowded ED may paradoxical-ly benefit hospital finances. For example, in U.S. hospitals, patients who use the ED are more likely to be uninsured or have government insurance and are less attrac-tive than pre-screened direct admissions which are more likely to have private in-surance, which pays higher rates. There-fore, many hospitals focus efforts on elec-tive cases rather than ensuring their EDs are efficient. In the U.S. and other parts of the world, the incentive to address ED crowding has started to change. Crowding measures such as ED length of stay are planned for U.S. public reporting; therefore, in the fu-ture, hospitals may have to compete on ED efficiency. Many U.S. EDs are already reporting waiting times on public bill-boards as a way to compete for paying pa-tients. Some countries are far ahead of the U.S. in reducing crowding and have man-dated limitations on ED lengths of stay. For example, from 2004–2005, the UK phased in a requirement that 98% of pa-tients leave the ED within 4 h [8]. More recently, New Zealand, Canada, and parts of Australia have created similar time lim-its for ED care ranging from 4–8 h. These time limits reduce crowding, but have al-so been criticized for unintended conse-quences, such as forcing dispositions that may occur in the final minutes before the time limit expires. In the UK, systems adapted to time limits, where patients re-quiring more prolonged work-ups were moved to different areas of the hospital, such as observation units. Just recently, the UK lifted the 4-h restriction on ED length of stay [9]. For hospitals that focus efforts on re-ducing ED crowding, there are many test-ed hospital-based solutions primarily fo-cusing on two areas: F improving throughput within the ED and F reducing the "access block" by focus-ing on eliminating the boarding of admitted patients.