WASHINGTON — Leaders from emergency medicine, hospital and nursing organizations, and insurance companies are looking for ways to make the public—and legislators—more aware of emergency department crowding and its potential impact on patient safety.
At a roundtable meeting convened by the American College of Emergency Physicians, the agenda also included discussion of what could be done to help stem the growing tide of “boarding” of patients and diversions away from overcrowded emergency departments (EDs).
The meeting was also attended by representatives from the American Hospital Association, the Federation of American Hospitals, the Joint Commission on Accreditation of Healthcare Organizations, the Emergency Nurses Association, and CareFirst BlueCross BlueShield.
Just ahead of the meeting, ACEP issued a survey showing that 69% of Americans believed that EDs are approaching a crisis situation because of overcrowding.
There were 114 million ED visits in 2003, the largest number of visits ever, and an increase of 2 million visits per year from 1993, said Robert Suter, M.D., quoting statistics from the Centers for Disease Control and Prevention.
The number of EDs declined by 14% over the same time period.
The most significant contributor to overcrowding is the practice of boarding, in which patients who've been designated as inpatients aren't admitted because of a backup in the hospital, said Dr. Suter, an associate professor at the University of Texas Southwestern Medical Center. They end up waiting in ED hallways or acute beds. In the poll, 77% of those surveyed said boarding should only be used as a last resort in extreme cases, such as a natural disaster or epidemic.
The backlog of ED patients often leads hospitals to divert ambulances to other facilities. Of the poll respondents, 55% said they were concerned about diversion; 35% of emergency medicine physicians said diversion was happening at their practice location. Hospitals are reporting a similar crowding crunch. In the AHA's 2005 Survey of Hospital Leaders, 69% of urban hospitals, 33% of rural hospitals, 79% of teaching hospitals, and 43% of nonteaching hospitals report that their EDs are at or over capacity, said Carolyn Steinberg, vice president of health trend analysis at the AHA.
Among all hospitals, 40% said they had been on diversion in the last year; 70% of urban hospitals and 74% of teaching hospitals had to divert ambulances.
The main reason for diversion was a lack of critical care beds, cited by 44% of hospitals. Other reasons cited included: an overcrowded ED (23%), a lack of general acute care beds (13%), staff shortages (9%), and a lack of specialty physician coverage (5%).
Patient boarding threatens the safety of patients and workers, and puts patients in undignified and unacceptable positions, said Bruce Auerbach, M.D., vice president and chief of emergency and ambulatory services at Sturdy Memorial Hospital in Attleboro, Mass. The roundtable group agreed on some operational solutions for hospitals, including creating a protocol for how to cope when an ED is at full capacity; creating observation or discharge holding units to help manage patient flow; working with administration to better manage the flow of inpatient elective surgery; and creating a community-wide diversion strategy so that the practice is used sparingly.
Diversion should not be eliminated entirely, the attendees agreed, in that it allows psychological relief for staff who are under stress and is sometimes necessary—for instance, with large numbers of casualties from natural disasters or accidents.
The attendees also urged policymakers to fully fund Medicaid, provide better access to quality care for the mentally ill, consider more pay-for-performance-based incentives, and increase EDs' spending from Homeland Security Department funds.