Overcrowding in the Emergency Department: Causes, Fallacies, and Fixes

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Emergency departments reflect everything good and bad about our nation’s healthcare system.
Emergency departments reflect everything good and bad about our nation’s healthcare system.

Emergency departments (EDs) are the Grand Central Station of medicine in this country. Serving an estimated 141.4 million patients a year and providing an average of 47.7% of all medical care delivered in the United States,1 EDs are the hub, the core, the main cattle crossing, and the big monkey cage of medicine.

Like giant mirrors, EDs reflect everything good and bad about our nation's healthcare system. And like lightning rods in a raging thunderstorm, they bear the brunt of all negative energy resulting from their often-cited and harshly criticized overcrowding problem.

But the truth is that fierce logjams in the ED, and the resulting plethora of proposed yet often unheeded solutions, are certainly nothing new. In fact, the whole topic of ED overcrowding is newsworthy only because it's pathognomonic of a deeper healthcare delivery system malady, and a failure on society's part to confront and come to grip with the real issues.

What contributes to overcrowding in the ED?

“There is no one, single, simple cause for overcrowding in the emergency department — rather, it's a complex multifactorial problem borne of a fundamental supply-and-demand mismatch,” says Jesse Pines, MD, FACEP, MBA, MSCE, director of the Center for Healthcare Innovation and Policy Research at the George Washington University School of Medicine & Health Sciences and a professor of emergency medicine and health policy & management at George Washington University in Washington, DC.

Dr Pines, who is an emergency physician by training, has first-hand experience with the variations in patient demand for ED services that can occur suddenly and unpredictably. "Overcrowding is not necessarily an all-the-time problem in every ED, but it is a some-of-the-time problem in most EDs, especially the larger ones," he continues.

The waiting is the hardest part

In her article “How to Fix the Emergency Room,” published in the Wall Street Journal, Ellie Kincaid writes, “Armed with new research and strategies borrowed from the business world, some facilities are trying to ease the frustrating experience of waiting, filling out forms, explaining a problem — and then waiting some more.”2

Certainly, having to wait in today's ED to be seen by a designated medical decision maker — whether that is a physician, a nurse practitioner, or a physician assistant — is frustrating at best. It's like trying to check into a hotel when you are road-weary and beat only to find a line of equally road-weary and beat travelers standing in front of you, clamoring for service — except much worse.

For this reason, whether public perception is accurate or not, many patients would almost prefer to die than go to the ED. But for patients who have no choice but to go to the ED — and there are many — the frustration of having to wait long hours to be seen due to ED overcrowding can be even more frustrating and more dangerous. 

A central cause of ED overcrowding is a phenomenon known as "boarding," defined by the American College of Emergency Physicians as "holding an admitted patient in the ED for hours or even days until an inpatient bed becomes available."3 

Overcrowding in the ED in general has been called a serious public health problem by the Institutes of Medicine.4 Boarding and crowding can result in increased patient morbidity and mortality while decreasing patient satisfaction. It is therefore a problem that most hospitals try to address by various means, but the incentives must be there to make this happen. 

Dr Pines and his colleagues published research in Health Affairs showing that despite the well-known problems of ED overcrowding and its tragic corollary boarding, many hospitals aren't getting with the program or doing anything about it.5

"There are capacity and non-capacity reasons for boarding," explains Dr Pines. "In the former case, there may simply not be enough beds available upstairs. But boarding can also result from administrative problems. There may be inefficiencies in how patients are transferred from one care team to another. In other cases, there may be plenty of beds, but these may be reserved for more lucrative patients — those coming into the hospital for elective surgeries, for example."

The picture is further complicated by the fact that just as no 2 patients are alike, no 2 EDs are alike. Each hospital ED, whether located in a large city or in rural America, struggles with its own unique set of problems.

A recent study, published in the Annals of Emergency Medicine, looked at how hospitals could pre-lubricate the ED logjam and get things moving more quickly and smoothly. Researchers found that 4 specific organizational characteristics seemed to help: executive leadership involvement, hospital-wide coordinated strategies, data-driven management, and performance accountability.4

But even the study investigators concluded that no one size fits all.

“Attempts to reduce ED crowding have a strong organizational culture; rather than adopting ‘generic' approaches, interventions should be selected and implemented to address the unique challenges of each hospital,” they wrote.

"There is nothing new about overcrowding in the ED — we've been overburdened for more than 2 decades," comments James Williams, MS, DO, FACEP, emergency medicine attending physician, Covenant Medical Center and clinical assistant professor at Texas Tech University Health Sciences Center in Lubbock.

"Many solutions have already been tried to make the ED more efficient," adds Dr Williams. "But these are only temporizing solutions, because there are more and more patients coming into the system each day, and the fundamental underlying supply-demand mismatch remains. Let's not delude ourselves — things are only going to get worse."

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