Ten Solutions for Emergency Department Crowding

Over the past decade, emergency department (ED) crowding has occurred and progressed. It has become a major topic of discussion at emergency medicine (EM) conferences, such as those held annually by the Society for Academic Emergency Medicine and the American College of Emergency Physicians. There has been much recent media coverage, such as the Newsweek article, “Code Blue for the ER.”1 Recently the Institute of Medicine published an extensive report on the topic.2 While there is no question that many EDs are crowded, the myriad causes of and solutions to crowding have been widely debated. In our opinion, multiple factors contribute to ED crowding, and the relative contribution of each factor varies between EDs. Circumstances differ between urban and rural hospitals, as well as between county, academic, and private hospitals.3 We believe multiple simultaneous steps are necessary to solve ED crowding. We present 10 putative solutions with commentary on actions at our institution to counter the problem. 1) Expand Hospital Capacity In 1946, at the end of World War II, the United States Congress addressed concerns with deficiencies in hospital bed capacity and health services by passing the Hill-Burton Act.4 This provided billions of dollars for hospital construction across the country, with the goal of five inpatient beds per1,000 persons. This wave of hospital construction attracted more people to careers in healthcare. Major funding ended in 1966, when the Medicare and Medicaid programs became law. By providing increased hospital capacity for its citizens, communities successfully attracted physicians, nurses and ancillary staff. Since 1970, the ratio of inpatient hospital beds per population has declined in the U.S. Unfortunately, with increasing numbers of uninsured and a requirement that hospitals run profitably, the number of hospital beds per 1,000 persons has diminished over the past 20 years. According to the California Healthcare Association, 70 hospitals closed in California between 1993 and 2003. California’s population grew by 13% during that time while acute care hospital bed capacity dropped by 14%. Today in California there are only 1.9 beds per 1,000 persons.5 As a result, many hospitals are perpetually full with admitted patients boarded in the ED. Boarding of inpatients in the ED is unquestionably the leading cause of crowding. At times the ED at the University of California, Davis has more boarded patients than new, ambulatory patients. We have contacted legislative staff locally and nationally about resurrecting the Hill-Burton Act to expand hospital capacity. This might be more appealing to Americans rather than radical reform of the healthcare system, advocated by some. Many health systems would welcome federal support to make this possible. Some might argue that increasing the number of hospital beds is not needed because of decreased length of stay for patients admitted to hospital more recently. We believe this is offset by the aging population and the number of complex medical conditions not considered and/or treated shortly after World War II. These includes chronic renal failure/dialysis, transplants, Hepatitis C, Acquired Immune Deficiency Syndrome, cancer chemotherapy, acute coronary syndrome and coronary artery bypass grafts, pacemakers, and many others. Many patients who would have died quickly or at home decades ago are kept alive for days to months, only to die in hospitals today.