Overcrowding in the nation’s emergency departments: Complex causes and disturbing effects,☆☆,

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Abstract

Ten years ago, serious overcrowding in emergency departments became a national issue. Although temporary improvement of the problem occurred, the issue of ED overcrowding has now resurfaced and threatens to become worse. Overcrowding is caused by a complex web of interrelated issues described in this article. ED overcrowding has multiple effects, including placing the patient at risk for poor outcome, prolonged pain and suffering of some patients, long patient waits, patient dissatisfaction, ambulance diversions in some cities, decreased physician productivity, increased frustration among medical staff, and violence. Solving the problem of overcrowding will not only require a major financial commitment from the federal government and local hospitals, but will also require a cooperation from managed care. Unless the problem is solved in the near future, the general public may no longer be able to rely on EDs for quality and timely emergency care, placing the people of this country at risk. [Derlet RW, Richards JR. Overcrowding in the nation’s emergency departments: complex causes and disturbing effects. Ann Emerg Med. January 2000;35:63-68.]

Introduction

We believe the issue of overcrowding in emergency departments has become a significant national problem. We base our opinion on discussions with emergency physicians across the country. Many private, academic, and urban EDs in both large and small communities are frequently subjecting patients to long delays compared with many years ago, when such overcrowding occurred primarily in inner-city EDs on Friday or Saturday nights.1 Recently in California, the State Department of Health threatened fines against some hospitals because of very serious and prolonged waits that lead to poor outcomes.2 The United States is not alone in the overcrowding problem. In Canada, the issue of overcrowding in “accident and emergency rooms” is a serious national issue.3 In Australia, ED overcrowding in Sydney has resulted in ambulance diversions from hospitals.4 Other countries, including Great Britain and Taiwan, have also reported overcrowding.5 The purpose of this article is to analyze some of the specific causes of overcrowding and describe some of the effects.

Overcrowding in EDs is difficult to define scientifically. It may be obvious to the average person when places such as supermarkets, international airports, and national parks are overcrowded, but arriving at the precise scientific definitions and thresholds are the subject of debate. Likewise, it may be obvious to the average person when an ED is overcrowded, but definitions based on precise wait times, or quantitative delays in actual ED care are lacking. Some have defined ED overcrowding on the basis of delays to transfer a patient to an inpatient bed,6 but this does not address other potential measures of overcrowding, such as front door to ED gurney time, significant delays in initial care, or use of the hallway as a treatment area. Some emergency physicians would define overcrowding as a situation in which demand for service exceeds the ability to provide care within a reasonable time, causing physicians and nurses to feel too rushed to provide quality care. In the authors’ opinion, real-time computerized tracking of waiting times, treatment times, and current census of actual number of patients in the ED being treated or waiting to be seen, are needed to accurately define overcrowding. However, few EDs have these.

What is the evidence for overcrowding? Overcrowding has been documented more with photos of congested EDs and anecdotal cases, and less with quantitative figures. Eight to 10 years ago, overcrowding in EDs was described in some metropolitan academic centers.6 A number of articles in the lay press and academic journals documented the problems related to providing adequate or even basic care to patients.7, 8 In 1990, Time magazine focused on overcrowded EDs in a detailed cover story.9 Documentation showed that patients suffered undue prolonged pain, inconvenience, and poor outcomes as a result of delays in emergency care. The American College of Emergency Physicians (ACEP) convened a task force and published a statement.10

In response, some hospitals invested more funds to enlarge EDs, enhance nursing staff, increase the number of physicians, and focus on providing better care to the patient. From 1990 to 1998, the number of emergency medicine residency programs increased 80% to 120 programs. Because of these measures, and growing concern that managed care might decrease ED volumes, little discussion occurred on overcrowding between 1992 and 1997. However, efforts to decrease overcrowding have not kept up with demand, and complaints among ED personnel have reopened discussions on overcrowding.11, 12, 13 A recent study found that 92% of academic emergency medicine EDs are overcrowded,14 and although inner-city, urban, and university hospitals have been the first to feel the effects of overcrowding, community and suburban EDs are also being affected.

Section snippets

Causes of overcrowding

ED overcrowding results from multiple complex and often interwoven issues. Taken together, the many changes that have occurred in EDs also have resulted in decreased physician productivity and efficiency. The most common causes of overcrowding include:

Effects of overcrowding

Overcrowded conditions in the ED have resulted in a number of different effects.

Solutions

The solutions to the problem of ED overcrowding are complex, expensive, and debated. A detailed analysis of potential solutions is beyond the scope of this article, and solutions have been described elsewhere. Some proposed solutions include (1) providing both insured and uninsured patients with better access to clinics; (2) expanding inpatient hospital bed capabilities, especially telemetry, and ICU; (3) development of ED observational units; (4) expansion of emergency physician, nursing, and

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    Address for reprints: Robert W. Derlet, MD, Emergency Department, University of California–Davis Medical Center, 2315 Stockton Boulevard, PSSB 2100, Sacramento, CA 95817; 916-734-8249, fax 916-734-7950; E-mail [email protected].

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