Emergency situation: Working harder unlikely to solve crisis in emergency room overcrowding

March 1, 2008

George Clooney's challenges make for good TV. While the former star of "ER" struggles with fictional patients, much of the drama in today's emergency department (ED) centers around the problems of overcrowding, increased utilization and increased wait times.

The problem facing today's EDs is one of simple supply and demand. On the supply side, the United States experienced a loss of 425 hospitals with emergency departments between 1993 and 2003, according to the Institute of Medicine's three-volume Future of Emergency Care report. That represented a 9% decrease in the number of EDs serving the population. At the same time, hospital closures reduced inpatient capacity by about 198,000 beds. This sharp decline in capacity was largely in response to cost-cutting measures, lower reimbursements by payers, shorter lengths of stay and reduced admissions under evolving care models.

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Unfortunately, the transition from the ED to a unit is often not a smooth one. Given the decrease in the number of hospital beds and the fact that elective admissions are more profitable than ED admissions, there's often a bottleneck between the ED and the main floors of the hospital. As a result, patients who need care are often "boarded" in the ED until a bed becomes available. Because boarded patients consume ED resources, EDs quickly become overcrowded. Waiting times increase and patients may be diverted to other hospitals.

A Government Accountability Office (GAO) study found that in 2001, 90% of hospitals boarded patients for at least two hours, and about 20% of hospitals reported an average boarding time of eight hours. It is not unusual for patients in a busy hospital to board for up to 24 or even 48 hours.

A study published in Health Affairs in January evaluated the change in wait time from 1997 to 2004 for adult ED patients. Harvard Medical School researchers at the Cambridge Health Alliance found that the median ED wait time went up from 22 minutes in 1997 to 30 minutes in 2004, a 36% increase. For patients diagnosed in the ED with acute myocardial infarction, or heart attack, the median wait time increased 15%, from 8 minutes in 1997 to 20 minutes in 2004. And for those identified in ED triage as needing attention "emergently," wait times increased from 10 minutes in 1997 to 14 minutes in 2004, an increase of 4% .