Overcrowding in U.S. EDS: A Critical Condition.

The California Journal of Emergency Medicine III:2, April 2002 page 24 ORIGINAL CONTRIBUTION Overcrowding in U.S. EDS: A Critical Condition Robert W. Derlet, MD University of California, Davis, Medical Center Sacramento, California rwderlet@ucdavis.edu The issue of overcrowding in Emergency Departments (EDs) has become a significant national problem. 1-5 Several recent scientific studies have added documentation of the overcrowding problem. 6-8 In addition, discussions with emergency physicians across the country and at national meetings indicate that this is a major problem. 9-11 Many private, academic, and urban EDs in both large and small communities are frequently subjecting patients to long de- lays compared with many years ago, when such overcrowd- ing occurred primarily in inner-city EDs on Friday or Satur- day nights. Recently, the issue of ED overcrowding was brought before the state legislator and other California agen- cies. 12-14 The United States is not alone in the overcrowd- ing problem. In Canada, the issue of overcrowding in “ac- cident and emergency rooms” is a serious national issue. 15 In Australia, ED overcrowding in Sydney has resulted in ambulance diversions from hospitals. Other countries, in- cluding Great Britain and Taiwan, have also reported over- crowding. 16,17 Overcrowding in EDs is difficult to define scientifically. It may be obvious to the average person when places such as shopping centers, international airports, and restaurants are overcrowded, but arriving at the precise scientific defi- nitions are the subject of debate. Likewise, it may be obvi- ous to the average person when an ED is overcrowded, but definitions based on precise wait times, or quantitative de- lays in actual ED care are lacking. Some have defined ED overcrowding on the basis of delays to transfer a patient to an inpatient bed, 18 but this does not address other poten- tial 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 rea- sonable time, causing physicians and nurses to feel too rushed to provide quality care. Real-time computerized tracking of waiting times, treatment times, and current cen- sus of actual number of patients in the ED being treated or waiting to be seen, are needed to accurately define over- crowding. However, not all EDs have these. Overcrowding has been documented more with photos of congested EDs and anecdotal cases, and less with quantita- tive figures. Eight to ten years ago, overcrowding in EDs was described in some metropolitan academic centers. 19-24 A number of articles in the lay press and academic journals documented the problems related to providing adequate or even basic care to patients. In 1990, Time magazine focused on overcrowded EDs in a detailed cover story. 25 Documen- tation showed that patients suffered undue prolonged pain, inconvenience, and poor outcomes as a result of delays in emergency care. The American College of Emergency Phy- sicians (ACEP) convened a task force and published a state- ment addressing these issues. 26,27 In response, some hospitals invested more funds to enlarge EDs, enhance nursing staff, increase the number of physi- cians, 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 over- crowding between 1992 and 1997. However, efforts to de- crease overcrowding have not kept up with demand, and complaints among ED personnel have reopened discussions on overcrowding. A recent study found that 92% of aca- demic emergency medicine EDs are overcrowded, and al- though inner-city, urban, and university hospitals have been the first to feel the effects of overcrowding, community and suburban EDs are also being affected. Overcrowding in EDs has reached the attention of major agencies including the CDC and AHA. Healthcare policy advisors and political leaders are faced with determining which are the most important causes that result in ED over- crowding. At present, while it is well-accepted that EDs are overcrowded, it is generally not agreed upon which causes are the significant ones that result in overcrowding. Alleged reasons for overcrowding include increases in popu- lation demographics, decreases in number of EDs, increase in acuity of patients presenting, increase in the number of elderly patients, shortage of nursing staff, shortage of phy- sician staff, shortage of residents in teaching hospitals, short- age of x-ray imaging equipment, shortage of on-call consult- ants, problems with language barriers and interpretation, an increase in the numbers of patients with chronic illnesses such as HIV, renal failure, congestive failure, and other prob- lems, inadequate physical plant space in the ED and increase in insured population and problems with access to HMO regulated clinics. Multiple groups agencies, organizations, and insurers are quick to blame anyone other than the area they control for