The impact of emergency department overcrowding on patient care and survival

The media has recently given great attention to the “crisis” in emergency department overcrowding, as if this were a recent development.  As far back as 1987, after sustained and unsolvable problems with crowding, the first statewide conference on overcrowding was held in New York City, involving NY ACEP, EMS, the NY State DOH, and legislators.  At that time, the issue was clearly delineated, but no clear solutions forthcoming.  Since that time, hospital and emergency department overcrowding has enjoyed cyclical media attention, but with little done to “fix” the problem.  How did we get there?

Hospitals in the ‘60’s were, in large part, a place for elective admissions, with only a small percentage of patients being unscheduled, or “emergent”.  There was also substantial capacity to allow for system-wide inefficiencies.  During this time, hospitals were run primarily as a 9-5, Monday through Friday business, with a skeleton crew on evenings, nights, and weekends.

When one fast-forwards to 2007, a dramatic change has occurred.  The majority of admissions are unscheduled.  As many previously inpatient procedures shift to the ambulatory setting, what was left behind is a much sicker patient population, filling the hospital to capacity. Rather than scheduled admissions, the majority of patients enter through the emergency department, with most of these entering the hospital in the afternoon and evening.  In most emergency departments, the volume of admissions varies little from day to day, or from weekday to weekend.  And yet, in far too many ways, hospitals have continued to function as a 9-5, Monday through Friday, institution, with a skeleton crew on evenings, nights, and weekends.  This may, in part, explain the higher death rate for strokes and heart attacks in patients admitted on weekends vs. weekdays.  With this mismatch of resource vs. need, there should be little surprise that capacity issues would arise.

Contrary to conventional wisdom that emergency department volume is highly unpredictable, the number of admissions per day can be predicted with remarkable accuracy. What is most striking about this fact is the associated fact that NO hospital actually anticipates and prepares for the next day’s volume of admissions from the emergency department.

How does the institutional structure create capacity issues by design?  A classic example is in surgical scheduling, which is not scheduled smoothly through the week, but rather front-loaded nearer to the beginning of the week.  Why?  For instance, an orthopedist knows that his or her patient undergoing hip replacement is critically dependent upon physical therapy in the days immediately following surgery, to prevent life-threatening postoperative complications.  If the hospital’s physical therapy staff is small or nonexistent on weekends, then the orthopedist has little choice but to schedule as much surgery as possible at the beginning of the week.  Thus, a “traffic jam” is created, where the hospital is loaded up earlier in the week.  This has a domino effect on the entire institution.  In fact, when an institution in Massachusetts, which had struggled with capacity issues for years, changed to a smooth surgical schedule, their capacity issues disappeared.

Crowding in the Emergency Department

Let us consider three topics as it relates to crowding of the ED.  First, what is it?  Second, what causes it (and what doesn’t)?  Third, and the focus of this chapter, what are the consequences to patients?

1.  Emergency department crowding:  what is it?

Various studies have developed definitions of ED crowding, but in its simplest form, crowding exists when there is no space left to meet the timely needs of the next patient in need of emergency care. If the care of urgent problems is delayed due to congestion, then crowding exists.

2.  Emergency department crowding – what causes it?

Over the years, the list of reasons for crowding have included:  unnecessary visits;  the poor and uninsured;  the safety net;  EMTALA;  and seasonal illness.  More recently, there has been far greater emphasis on the boarding of admitted patients as the primary cause of ED overcrowding.  That is, the practice of leaving admissions in the ED when there is no “proper” space within the institution is the source of delays in patient care. Let’s take each of these issues in turn. 

The clearest cause of crowding:  boarding of admitted patients.

A number of recent studies have shown a direct and strong correlation between the number of admissions being boarded in the emergency department and crowding, making it clear beyond question that this is the number one culprit related to ED overcrowding.  In short, it is not really the ED which is overcrowded.  It is the hospital which is overcrowded.

It is important to distinguish what crowding means in the emergency department vs. the inpatient units in most hospitals.  Inpatient units, when their normal patient beds are full, are considered “full” and thus not “capable” of taking more patients.  Emergency departments are considered “full” when all of their rooms are full;  all of their hallway stretchers are full;  and all of their chairs are full.  Thus, there is striking contrast between the ED and the inpatient units in their respective views of what constitutes “at capacity”.

3.  What are the consequences of crowding?

A wealth of literature exists which demonstrates the consequences of crowding in the emergency department.  These consequences include:

A.  Sick people have to wait too long to receive care

In fact, the CDC reported that, for patients judged by the triage nurse to be critical, over 10% of this group waited more than an hour to see a physician.[i]  Many illnesses are time dependent.  Earlier intervention gives rise to better outcome. Late diagnoses may sometimes be too late, with permanent consequences of disability or death.[ii]  Waiting times can be reduced by reducing access block.[iii]

Pines studied the complication rate of ACS patients as a function of crowded vs. noncrowded conditions, and found a significant increase in serious complications (approximately 6% vs. 3% incidence of death, cardiac arrest, heart failure, late MI, VTach or VFib, SVT, bardycardia, stroke, or hypotension) in those patients presenting during times of crowding.[iv]

B.  Boarding increases TOTAL length of stay in the hospital, further worsening access.

Some 5 + studies have documented a total hospital length of stay to be a full day longer in patents boarded in the ED vs. patients with similar illnesses promptly placed on the inpatient units.[v],[vi],[vii]

C.   Boarding increases walkouts, some needing admission

The longer the wait, the greater the number of people who leave prior to care. [viii] Unfortunately, the percent of patients with serious illness differs little in the group who left vs. the group which awaited care. A number of these walkouts will require subsequent admission.[ix]

D.  Overcrowding increases medical errors

A number of articles document the increase in medical errors associated with boarding of admissions and crowding.[x]  Many of these are errors of omission, as the emergency staff must focus on the new emergencies coming in the door.[xi]  According to JCAHO, 50% of sentinel events occur in the ED, and approximately 1/3 of these are related ot overcrowding.[xii]

Boarded admissions are at risk of adverse event or error. For example, a review of 162 boarded admissions noted a total of 43 medical errors (4 upgrades, 2 poorly controlled BP, 1 hypoxic event, 9 missed medications, 31 missed home medications, 4 missed laboratory tests, 2 arrhythmias) during the period of boarding.[xiii]

E.  Overcrowding causes deaths

The emergency medicine community has long been aware of the dangers of overcrowding and delays in care, but have an understandable reluctance to publish bad outcomes.  Several recent articles, looking at large databases which compare mortality rates in patients presenting during times of crowding vs. times of no crowding, conclude that the rate of death is higher during times of crowding.  This effect (hazard ratio for death of approximately 1.3)[xiv], [xv]  is larger than the risk of other initiatives given great importance, such as the administration of antibiotics fo pneumonia patients within 4 hours.  Compliance with this initiative is estimated to reduce the number per 100 who would have died from 100 to 93.  Overcrowding studies estimate that the reduction of deaths would be reduced from 100 to a range estimated between 75 and 83.  These are substantial numbers, and apply to a very large population. As such, it may be a far more important issue to resolve.

Chalfin and colleagues looked at the outcomes of ICU patients subjected to a delay of >6 hours in transfer to an ICU, and found increased hospital length of stay (7 vs. 6 days) and higher mortality rates (10.7% vs. 8.4%) for these patients.[xvi]

F.  Overcrowding causes ambulance diversion

According to the CDC, approximately 50 percent of EDs experience crowding, and 1/3 of US hospitals have experienced ambulance diversion.[xvii] Ninety percent of ED directors report overcrowding as a recurrent problem,[xviii] and other studies have reported diversion in up to 50% of emergency departments.[xix]  Such crowding and diversion have raised an alarm regarding the ability of the health care system to respond to catastrophe.[xx]

Interestingly, there is scant evidence that ambulance diversion actually works,[xxi] although evidence exists for delayed care in the face of ambulance diversion.[xxii] In this regard, Nicholl demonstrated an increased mortality rate with prolonged transport times.[xxiii]

What should be clear is that ambulance diversion is driven by the boarding of admitted patients, and not otherwise related to issues of staffing or space within the ED itself.[xxiv]

G.  Overcrowding harms physicians

The frequency of malpractice suits filed against an emergency physician is increased by a factor of 5, simply based on whether the patient waited more than, rather than less than, 30 minutes to be seen by the physician.

In summary, boarding increases harm to patients in the following ways:

·        Waiting times

·        Diversions

·        Length of stay

·        Medical errors

·        Sentinel events

·        MORTALITY

·        Boarding increases harm to hospitals and doctors in the following ways:

o       Financial losses to hospital and MD

o       Malpractice claims