Healthcare Delivery Solutions: An Evidenced Appraisal of ED Crowding

By Emilio S. Belavel, MD, FAAEM, Chief Medical Advisor

A recent report by the Journal of the American Medical Association (JAMA) finds that over the last two decades, the number of U.S. hospital emergency departments (ED) in urban areas has declined by about 27 percent: In 1990, the nation had about 2,446 EDs in non-rural areas; today there are 1,779.

Researchers blame the decrease mainly on economics. By law, EDs must treat everyone, regardless of their ability to pay. However, the argument around ED economics is somewhat convoluted. A different report (mentioned in our blog, posted 5/9/11), points to the vast majority of emergency room visitors with health coverage who are referred to EDs by their doctors. Obviously, other factors weigh in, and JAMA study researchers admit that little is known about those factors.

It’s also true that EDs in rural and non-urban areas are at risk for crowding. By 2001, it was recognized as a national crisis, rapidly becoming more prevalent and impacting all ED locations and settings.

So the problem is pervasive.

As a result, patients are experiencing longer delays in both traveling to EDs and in waiting for care once they get there. The issue has already resulted in medical errors and patient safety concerns—delays in antibiotic administration, treatment for patients with heart conditions, pain management, and critical care.

To deal with the complex interplay of issues around the causes and impacts of ED crowding, we must turn to hospital-wide reorganization and operational redesign. The aim is to eliminate waste and inconsistency at all system levels, including internal processes, asset utilization patterns, resource allocations, capacity management protocols, people factors, and support interfaces.

It is evident by now that no single intervention or even a multitude of interventions without holistic change can help a hospital solve the complex web of systemic deficiencies that culminate to ED crowding. Only a fundamental bottom-up redesign of ED operations, ancillary support interfaces, and hospital capacity management procedures can effectively solve the problem.

To drive the discussion for change at your organization, I invite you to read a recent article that I co-authored with Jesse Pines, M.D.: Emergency Department Crowding: An Evidenced-Based Appraisal of the Problem and Its Solutions , which takes a comprehensive view of the causes and effects of ED crowding, as well as evidence-based strategies to address them.