- Emergency physicians are committed to providing high-quality emergency care as quickly as possible to all patients, but crowding and boarding jeopardize patient safety.
- The sharp rise in the number of emergency patients (136 million in 2011[i]) combined with critical shortages throughout the entire emergency medical care system limit everyone’s access to timely emergency care.
- Patients who need to be seen in 1 to 14 minutes are being seen in twice that timeframe (37 minutes), according to the GAO in 2009.[ii]
- Effective low-cost solutions to crowding exist that can be implemented now, but there has to be buy-in from everyone in the hospital, not just the emergency department.
Q. What causes long wait times and crowding in emergency departments, also known as ERs?
- Triage. Patients are not seen on a first-come, first-served basis. The most critically ill or injured patients are seen first. A triage nurse or care provider assesses the severity of patients’ conditions when they arrive to determine who sees the physician right away and who might have to wait. Health care providers have special training to determine how time-sensitive an illness or injury is. Just because someone in the waiting room doesn’t look sick doesn’t mean they aren’t sick.
- Diagnosis. Diagnosing a medical condition can take a long time, especially when the emergency physician is ruling out life-threatening conditions. Tests, blood analysis, medical treatment and imaging studies – such as x-rays and CT scans – take time. A study published in Annals of Emergency Medicine found growing numbers of patients require more complex and longer workups. [iii] Even after life-threatening conditions have been ruled out, emergency physicians may end up referring an emergency patient to a specialist for a full workup and diagnosis.
- Boarding. One of the biggest causes of crowding and wait times in emergency departments is “boarding,” which is the term for holding an admitted patient in the ER for hours or even days until an inpatient bed becomes available. Hospitals restrict the number of inpatient beds available to patients admitted from the emergency department, which keeps these patients from being moved “upstairs,” out of the emergency department. Admitted patients will continue to be provided high quality care by the emergency staff, preventing them from attending to new patients coming in, which leads to long waits. According to the Centers for Disease Control and Prevention, 62 percent of hospitals reported some admitted patients being boarded for two hours or more at some point in the past year.[iv]
- Specialists. Patients may wait for care if a specialist who treats their type of illness or injury cannot be located. Emergency physicians are available 24 hours a day, 7 days a week, but other medical specialists – such as neurosurgeons, cardiologists and orthopedic surgeons – provide “on-call” backup services as needed. An increasing number of these specialists will not take call in the ER due to concerns about reimbursement and being sued. In extreme cases, patients requiring the services of a specialist may be moved to another hospital, or even to another state, to get the care they need.
- Disasters. Surges in emergency patients, which may be caused by mass casualty events, natural disasters or local disease outbreaks (such as flu) may tie up all of the staff and resources of an emergency department at once.
- Closures. Between 1993 and 2013, the number of emergency departments decreased nationally by 11 percent[v], while the annual number of emergency department visits increased by 51 percent.[vi] More and more patients are relying on fewer and fewer emergency departments, leading to longer wait times for everyone.
- Staffing. Many hospitals plan staffing and scheduling to be heaviest from Monday to Friday between the hours of 9 AM and 5 PM, even though more than half of patients come to emergency departments after typical business hours (evenings and weekends) [vii]. A 2012 paper in Health Affairs said solutions to boarding and crowding – such as scheduling surgeries and hospital discharges more evenly throughout the full week – are “grossly underused.”[viii]
Q. Can patients be harmed by waiting?
- Yes. In 2012, Annals of Emergency Medicine published a study finding that patients admitted to the hospital from the emergency department during periods of high crowding died more often than similar patients admitted to the same hospital when the emergency department was less crowded. Crowding was also associated with longer overall hospital length of stay.[ix] Typical, the driver of crowding and long wait times is boarding, or the practice of holding admitted patients in the emergency department because there are no in-patient beds for them.
- Long waits can affect patient outcomes in other dangerous ways. Patients may get tired of waiting and leave without receiving medical treatment. Emergency departments work hard to make sure the sickest patients are seen first and that all patients are seen in a timely manner, but when the resources of the emergency department are overwhelmed, patients may wait dangerously long for care.
- When emergency departments reach such a saturation point that they can no longer accept patients, they may divert ambulances to other hospitals. These diversions can lead to dangerous delays in care. A survey conducted in 2010 by the American Hospital Association found 17 percent of hospital reported their emergency department was “over capacity” at some point during the previous month.[x]
Q. What is the average length of time people spend in emergency departments?
- The average length of time that people spent in the emergency department nationwide, from arrival to discharge or admissions, is two hours and 15 minutes. [xi] However, the average waiting time varies state by state, with some states reporting average stays in the emergency department of 3 hours or more.
Q. Do patients with minor problems increase wait times?
Patients with minor problems do not increase wait times for other patients. A study published in Annals of Emergency Medicine found that “reducing the number of low-complexity emergency department patients is unlikely to reduce waiting times for other patients.”[xii] The Centers for Disease Control and Prevention reports that less than 4 percent of all emergency patients are classified as non-urgent, meaning they need care in 2 to 24 hours.[xiii] Patients with minor problems typically wait longer for care than any other patients because of the triage process that places the sickest patients at the head of the line. Additionally, once seen, patients with minor problems typically leave the emergency department quicker than sicker and admitted patients.
Q. Why are emergency departments under so much stress?
- More and more patients are relying on fewer and fewer emergency departments. Emergency visit rates have increased at twice the rate of growth of the U.S. population from 1997 to 2007.[xiv] As the Baby Boom generation ages into retirement, a growing number of elderly patients with complicated health problems will seek medical care in emergency departments, leading to crowding that a 2007 study in Annals of Emergency Medicine forecast could become “catastrophic.”[xv]
- Although millions of Americans obtained health insurance following the enactment of the Affordable Care Act (ACA), shortages of primary care physicians and other office-based doctors left many patients with limited access to care. According to a paper published by Health Policy Alternatives in 2015, more than half of providers listed by Medicaid managed care plans could not offer appointments to enrollees. The median wait times was 2 weeks but over one-quarter of providers had wait times of more than a month for an appointment.[xvi]
- Shortages of hospital inpatient beds, physicians and nurses are exerting more pressure on the emergency medical care system. During the 1990s, hospitals lost 103,000 staffed inpatient beds and 7,800 ICU beds.[xvii] Studies of the physician workforce estimate that the United States will be short upwards of 24,000 physicians by 2020.[xviii]
Q. What are the solutions to overcrowding?
- Move admitted patients out of the emergency department to different inpatient areas. With each unit taking a small number of patients, the burden of boarding is more evenly spread through the hospital, thus enabling the emergency department to better care for emergencies.[xix]
- Coordinate the discharge of hospital patients before 12 noon. Research shows that timely departure from the hospital can significantly improve the flow of patients in emergency departments by making more inpatient beds available to emergency patients.
- Coordinate the scheduling of elective patients and surgical cases. Studies demonstrate that the uneven influx of elective patients (heaviest early in the week) is a prime contributor to exceeding capacity in inpatient units.
- Other solutions extend to other parts of the health care system and include:
- Increase outpatient access by extending primary care’s evening and weekend hours.
- Reduce readmissions by having discharge strategies for prompt follow up visits after discharges.
- Increase investment into observation units to expedite short stay discharges the next day.
- Have a multidisciplinary complex care clinic for patients with multiple comorbid conditions that could potentially be seen the next day instead of admitted to the hospital.
- Work with nursing homes / long term care facilities to shorten the approval period to accept patients waiting to be discharged from hospital. Eliminate the Medicare-required 3-day hospital stay prior to admission to nursing home.
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[ii] United States Government Accountability Office, April 2009, Hospital Emergency Departments: Crowding Continues to Occur, and Some Patients Wait Longer than Recommended Time Frames.
[iii] Annals of Emergency Medicine, 2012, “National Trends in Emergency Department Occupancy, 2001-2008: Impact of Inpatient Admissions Versus Emergency Department Practice Intensity,” Stephen Pitts, et al.
[iv] National Hospital Ambulatory Medical Care Survey: 2011 Emergency Department Summary Tables, Table 27
[v] American Hospital Association Trendbook 2015 Table 3.3 http://www.aha.org/research/reports/tw/chartbook/ch3.shtml
[vi] Health Affairs, August 2014, “California Emergency Department Closures Are Associated with Increased Inpatient Mortality at Nearby Hospitals,” Charles Liu, et al.
[vii] AHA analysis of Centers for Disease Control and Prevention, National Ambulatory Medicare Care Survey data, 2010
[viii] Health Affairs, August 2012, “Solutions to Emergency Department Boarding and Crowding Are Underused and May Need To Be Legislated,” Elaine Rabin et al.
[ix] Annals of Emergency Medicine, 2012, “Impact of Emergency Department Crowding on Outcomes of Admitted Patients”
[x] Press Ganey 2010 Pulse Report: Emergency Department Patient Perspectives on American Health Care.
[xii] Annals of Emergency Medicine, 2006, “The Effect of Low-Complexity Patients on Emergency Department Waiting Times,” Michael Schull.
[xiv] Journal of the American Medical Association 2010, “Trends and Characteristics of US Emergency Department Visits, 1997-2007,” Renee Hsia et al.
[xv] Annals of Emergency Medicine 2007, “Increasing Rates of Emergency Department Visits for Elderly Patients in the United States, 1993 to 2003,” Mary Pat McKay, et al.
[xvi] Health Policy Alternatives 2015, “Review of the Evidence on the Use of the Emergency Department by Medicaid Patients and the Evolving Role of Emergency Medicine Physicians,” http://newsroom.acep.org/statistics_and_reports?item=30111
[xvii] Centers for Disease Control and Prevention 2010, “In a Moment’s Notice, Surge Capacity for Terrorist Bombings”
[xviii] Healthleaders, September 22, 2008, “Staffing Crunch Threatens Healthcare,” John Commins.
[xix] ACEP Task Force on Boarding report, 2008, Emergency Department Crowding: High-Impact Solutions
(Last Updated 2016)