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.”

One misperception held by the public is that ED overcrowding is substantially exacerbated by patients who really don’t need to be there — the so-called “frequent flyers” who come in with chronic pain conditions seeking narcotics alone, for example, or who are homeless and use the ED for a quick meal and shelter from the storm or other psychosocial reasons.

And while there will always be a small subset of people who will abuse, or try to abuse, the system for reasons not truly emergent or critical to their health, research shows that most patients in the ED really need to be there, and that non-urgent or low-acuity cases account for less than 8% of all ED visits, and do not contribute to overcrowding.6

One is well-advised to remember that EDs are open 24/7, and equipped to handle truly life-threatening situations and other less acute conditions. And because of Emergency Medical Treatment and Labor Act mandates, EDs are required to see and treat anyone who walks in at any time, regardless of that individual’s ability to pay. EDs are unique in this regard.

Not even urgent care clinics — which offer hours and days of operation beyond that of a typical primary care office and are often viewed as an alternative to the ED for less acute conditions — are open 24 hours a day. Moreover, urgent care clinics typically require proof of insurance, co-pay, or cash payment up front.

If ever there were such a thing as a true safety net in medicine, it would be the ED.

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The real elephant in the room

“One critical question: what’s the patient’s responsibility in all of this?” Dr Williams inquires. “One-third of the US [population] is obese. And what are the health consequences of this? Hypertension, fatty livers, increased musculoskeletal problems, diabetes, heart disease and stroke. Unless we address these things, nothing is going to change with overcrowding in the ED.”

Indeed, the National Council on Aging states that, “chronic diseases account for 75% of the money our nation spends on health care, yet only 1% of health dollars are spent on public efforts to improve overall health.”7

“Patients look to everyone else to take care of them: third-party health plans, Medicaid, Medicare, the so-called insurance exchanges,” explains Dr Williams. “Because most have some form of health insurance, they believe they should be guaranteed access to care. And not only access, but fast access. From a macroeconomic standpoint, we cannot continue to support the current system. It is unsustainable.”

Against this backdrop is a national trend toward hospital closures and consolidations. This trend has hit rural hospitals particularly hard. Hospitals are closing because the cost of keeping the hospital up and running is greater than the revenues generated by the hospital. Most not-for-profit and public hospitals operate on a pretty slim margin to begin with, and that margin is trending downward from 3.4% in the 2015 fiscal year to 2.7% in 2016, according to Moody’s Investors Service.8

Christopher Pope, BSc, MA, PhD, a senior fellow at the Manhattan Institute in New York says, “Over recent years, numerous rural health insurance markets have teetered on the brink of collapse. Rural areas have long posed a special challenge to healthcare policymakers, but a poorly-designed system of subsidies for rural hospital care has turned this into a crisis.”9

When hospitals close, communities lose their EDs. This can be devastating and amount to a true public health debacle, especially in remote rural regions far removed from the tertiary care facilities and level 1 trauma centers easily found in major metropolitan areas.

There can be no doubt that we need a more equitable, stable, and balanced system of reimbursement for our hospitals, large and small, that compensates them adequately for the highly vulnerable populations they serve.

I’m talking about seniors who are now living longer, with more comorbidities and complex polypharmacy issues, the indigent, the suddenly relocated, or the marginalized members of our society. Or maybe just common folks like you and me who happen to get sick in the middle of the night.

“Emergency departments serve a vital community and national role,” emphasizes Dr Williams. “For 50% of all patients we are the front door to healthcare. More than 90% of our patients do indeed have emergencies and need immediate care. But we also serve as a safety net for a large portion of the population. The [Affordable Care Act] gave some people health insurance but gave no one healthcare. The emergency department provides care to everyone throughout the country. We need appropriate funding and allocation of resources to care for this group because it will likely only get larger.”  

The ED, overcrowded though it may be at times, is uniquely qualified to serve us. Bottom line: we should praise it, defend it, and do all we can to support it by repairing the cracks in our badly fragmented healthcare system. 

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References 

  1. Marcozzi D, Carr B, Liferudge A, et al. Trends in the contribution of emergency departments to the provision of health care in the USA [published online October 17, 2017]. Int J Health Serv. doi:10.1177/0020731417734498
  2. Kincaid E. How to fix the emergency room. The Wall Street Journal. Available at: www.wsj.com/articles/how-to-fix-the-emergency-room-1505268780. Published September 12, 2017. Accessed October 26, 2017.  
  3. Emergency department wait times, crowding and access fact sheet. American College of Emergency Physicians. Available at: http://newsroom.acep.org/fact_sheets?item=29937. Accessed October 26, 2017.
  4. Chang AM, Cohen DJ, Lin A, et al. Hospital strategies for reducing emergency department crowding: a mixed-methods study [published online August 25, 2017]. Ann Emerg Med. doi:10.1016/j.annemergmed.2017.07.022
  5. Warner LS, Pines JM, Chambers JG, Schuur JD. The most crowded US hospital emergency departments did not adopt effective interventions to improve flow, 2007–10. Health Aff (Milwood). 2015;34(12):2151-2159.
  6. Myths and facts about emergency care. American College of Emergency Physicians.Available at: http://newsroom.acep.org/fact_sheets?item=30031. Accessed October 26, 2017.
  7. Fact Sheet: Chronic disease self-management. National Council on Aging. www.ncoa.org/resources/fact-sheet-cdsmp/. Accessed October 26, 2017.
  8. Hospital profit margins declined from 2015 to 2016, Moody’s finds. Advisory Board. Available at: www.advisory.com/daily-briefing/2017/05/18/moodys-report. Published May 18, 2017. Accessed October 26, 2017.
  9. Pope C. What’s causing America’s rural health insurance crisis? RealClear Health. Available at: http://www.realclearhealth.com/articles/2017/10/20/whats_causing_americas_rural_health_

           insurance_crisis_110736.html. Published October 20, 2017. Accessed October 26, 2017.

This article originally appeared on Medical Bag