Essay on "Emergency Room Overcrowding"

Essay 10 pages (3106 words) Sources: 10 Style: APA

[EXCERPT] . . . .

Emergency Room Overcrowding

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There is little doubt that patient boarding -- holding patients in the emergency department (ED) after they are ready to be admitted to in-patient care -- is the main cause of emergency room overcrowding in hospitals in this country. An overwhelming base of knowledge and research indicates the long-held myth that indigent patients are the cause of the almost catastrophic problem of ED overcrowding is based on opinion and perception but not fact.

Actually, the increase in ED patronage is due to middle-income people who already have some source of health care. This has important repercussions for President Obama's emphasis on passing universal health care because it means that providing health insurance for everyone will not, by itself, solve the problem of overcrowding.

Many contributors to the increase in visits to EDs exist: population increases, the aging of our population, the increased numbers of time-sensitive interventions requiring state-of-the-art hospital care, larger numbers of patients with complex medical problems requiring evaluation in a setting in which sophisticated testing and consultation are available, and complications from medical and surgical treatments (Bernstein, 2008, para. 9).

There is also truth to the fact that the number of EDs in this country are shrinking at an alarming rate and that this is a contributing factor to overcrowding, but expert after expert will vouch that hospital admission procedures and the non-use of "full-capacity protocol" -- the frequent and constant co-ordination between ED and in-patient care to ensure 100% of the in-patient hospital beds are being utilized -- are, by far, the tall poles in the tent regarding fixing the overcrowding situation. It is the lack of effective use of full-capacity protocol that most demands attention and implementation to alleviate patient boarding.

The Myriad Problems

About 100 million patients visit EDs every year to receive some form of emergency care.

In 1958, a study forecast the necessity of building new emergency facilities. Since that study, ED visits have increased 650%. The number of additional emergency facilities has not kept pace. We made it clear that no one factor caused this overcrowding. It is the result of a long list of complicated legislative, social, and financial factors (Committee on Pediatric Emergency Medicine, 2004, p.878).

According to the American Hospital Association, there were 1.36 million inpatient beds in 6933 hospitals in 1981, 927,000 staffed beds in 5370 hospitals in 1991, and 829-000 beds in 4956 hospitals in 1999 (American Hospital Association, 1999).

In Texas, some hospitals have seen ER volumes increase by 2.5% in the last 12 months. "That's 70,000 visits a year in our two facilities," says Art Chance, VP of Operations at East Texas Medical Center. Things are so bad there that they are warning patients who really don't need emergency care to go elsewhere for treatment (Chance, 2009).

To place this enormous problem in perspective, we must also understand that this is not just a U.S. problem but a world-wide emergency that needs to be addressed. Note what the Australiasian College of Emergency Physicians suggests as the solution to the problem:

"Overcrowding in the nation's emergency departments is killing 1,500 people a year, according to the Australasian College of Emergency Physicians. Recent research suggests that these avoidable deaths occur because there just are not enough beds in the rest of the hospital system to take emergency patients once they need more specialized, longer term care" (Epstein, 2009, para. 1).

In the U.S., trained emergency physicians are in short supply. And the backbone of every ED -- well-trained emergency-care registered nurses -- are in critical shortage. In some states, the vacancy rate of these RNs is 30%. As a result, EDs and hospitals are forced to cut back on services.

Enormous increases in liability insurance premiums are also a culprit. Increases in some states for certain sub-specialists can reach 25-50% annually. The problem here is that physicians that specialize in ED work pay more for insurance than others. Many decide that ED service is just not worth the cost or the liability.

Patients who need emergency care are backed up to the point that loss of life occurs in some cases. Dr. Robert Rosenbloom, President of the California Chapter of the American College of Emergency Physicians says this: "Long waits mean patients don't get the treatment they need when they need it. We have had to resuscitate patients in waiting rooms and hallways because the ER is full" (Gozzo, 2009, para. 4)

Linda Laurence, president of the American College of Emergency Physicians:

"Assumptions that uninsured patients make use of EDs for non-emergency care have been a huge barrier in efforts to reform emergency care. The reason for emergency department overcrowding is the practice of inpatient boarding" (GetInsideHealth, 2008, para. 5).

Solutions Offerred

Many hospitals are using their own creativity to resort to on-the-spot procedures to make processes more efficient. Quick registration, bedside registration, standing orders for certain emergencies instead of having to seek out a doctor and obtain sign-off, and the use of fast-track and sub-waiting areas are all being utilized at EDs across the nation.

But for many, these are temporary and there is no more to be done -- and patients still wait.

For a time, hospitals placed some hope that retail health clinics like Emergi-Care and Minute Clinic could alleviate some of the load. But studies have found that 95% of patients utilizing such clinics would have otherwise sought care at a physician's office or other clinic, and not at an ED (Bachenheimer, 2008).

A complete "re-engineering" of current systems to allow for minimal waiting and transport to a clean available bed on an inpatient floor is the solution, many experts agree. Implementation is complicated, expensive, and not guaranteed but includes the following: (Bachenheimer, 2008)

Greatly simplify the hospital admission process.

Prioritize hospital resources for the ED. In 1996 emergency patients comprised 36% of all hospital admissions, according to the Centers for Disease Control (CDC). Today that stands at between 50% - 75%, but hospitals are not allocating the resources in a representative proportion to their "top moneymaker." Whether it is space, equipment, number of physicians and nurses, or dollars, EDs are not as well represented in hospital budgets and allocations as they should be.

Reduce non-urgent visits to emergency departments. (considered crucial to success)

Initiate "full-capacity protocol" through legislation if necessary, at all EDs.

The highly regarded Press Ganey Emergency Department Pulse Report 2009, analyzed data from about 1.4 million patient experiences in over 1,700 EDs across the U.S. For the 2009 report.

The report shows that the average ED patient spent four hours and three minutes door-to-door in ED. That is an increase of 27 minutes, over 10%, from 2002 (Press Ganey, 2009, ).

The Press Ganey Report, based on this massive amount of data, further concluded that "the best way to get patients treated and discharged from the ED is to address overcrowding in general and get the critical patients through the ED and to the appropriate floor faster" (Press Ganey, 2009, para. 4).

In June, 2009, in California, Assemblyman Ted Lieu announced a bill that will significantly lower the levels of overcrowding in California EDs. California ranks 50th of 50 states in the number of EDs; they provide only six emergency rooms to each one million patients.

Lieu's bill will implement a policy of "full capacity protocol." This will expedite the processing and flow of patients through EDs and into inpatient beds, the major problem present in California's EDs. The legislation will force hospitals and EDs to evaluate the overcrowding conditions vs. beds available in the hospital every three hours, and coordinate action to fix the blockages.

Finally, the American College of Emergency Physicians in their 2008 Task Force Report, ask and answer the question: "What Causes Crowding (in EDs)?" Their answer, unequivocally, is patient boarding -- that practice of holding admitted patients in the ED when there is no "proper" space of them in the hospital (ACEP, 2008, p. 8).

So, Let's Talk About Patient Boarding

All of the factors we have discussed above contribute to the overall crisis of overcrowding in EDs across our country. There is no question that EDs across this country are overcrowded. Yes, there are many more ED patients and fewer EDs to handle them. But the research is telling us that we could handle the overflow even with the limited resources we have, and reduce the wait times, if we could clear the treated patients faster and get them back out the door or to inpatient hospital beds. It is this shortcoming in our hospital internal processes that must be addressed. There is also no question that the mystery as to why has been solved after so many years of assumptions that have turned out to be incorrect. Study after study, and prestigious groups involved in ED practices, all agree that patient boarding is the culprit. The good news is that there a number of… READ MORE

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