A proposal for a new accreditation standard to reduce overcrowding in emergency departments touched off a defensive reaction last week from provider representatives who said the responsibility for fixing the problem, largely the result of a string of societal failures, should not be laid at the emergency room door.
The Joint Commission on Accreditation of Healthcare Organizations floated a set of new requirements for public comment amid mounting evidence that delays in treating seriously ill people in hospitals, especially in the emergency department, are leading to unnecessary deaths and complications.
A draft of the standard, which is open to public comment through June 2, calls on hospital leadership to implement plans to efficiently move patients through a healthcare facility, incorporate the issue of emergency room overcrowding into performance improvement activities, predict and monitor the capacity of areas that receive emergency patients, and plan for the care of patients placed in temporary beds.
The standard also requires hospitals to work with other community services to better coordinate the flow of emergency cases into and out of the ER, from paramedic and ambulance services to long-term-care and home health agencies.
But hospitals' ability to respond to the crush of volume is hampered by the consequences of primary-care breakdowns, severe nursing shortages, lack of capital for information technology and other issues that are all affecting the emergency department, said Don Nielsen, senior vice president of quality leadership at the American Hospital Association.
"The hospital emergency room is not the fix for an overburdened healthcare system that is broken," Nielsen said. "The Joint Commission is short on posing solutions. They're good at imposing additional requirements."
"The JCAHO would like hospitals to solve a problem not created by hospitals," said Belinda Dixon, director of physician practices at Little Company of Mary Hospital in Evergreen Park, Ill. "ERs are overcrowded due to inappropriate visits to the ER for health issues that could be taken care of in a doctor's office or health issues that should have been managed by a primary-care physician all along to avoid acute episodes requiring emergency care."
The Federation of American Hospitals was still studying the standard last week, but "the initial reaction is not positive," said spokesman Richard Coorsh. The proposed requirements "appear to hold individual hospitals responsible for some of the problems (in the ER) which are largely societal in nature."
But JCAHO officials said they also are analyzing the policy and social issues underlying the problem, which will lead to a push this summer for more fundamental solutions and broader accountability. "To do the standards without also having a public policy initiative would not make sense," said Robert Wise, the commission's vice president of standards. "The bigger solution cannot sit with hospitals; everyone agrees with that."
The genesis of the proposed standard, Wise said, was a series of roundtable discussions last year on issues that contribute to emergency department overcrowding, along with the consequent problems of delayed treatment in hospitals and the ill effects on patients.
The JCAHO had issued an alert in July 2002 about catastrophic delays in hospital treatment, culled from its database of "sentinel events"-incidents involving death or serious injury. Of the 55 reported delays, 52 resulted in patient death. Half the cases were ER-related, and overcrowding was cited as a factor in 31% of those cases. Since then, the reported number of treatment delays resulting in sentinel events more than doubled to 122, of which 49 were related to ER care.
The commission adopted the ER overcrowding issue as the third initiative of a campaign launched last year to influence public policy affecting quality of care. Previous "calls to action" covered nurse-staffing shortages and the need to organize communitywide responses to bioterror emergencies.
A national symposium on ER problems in February amassed information that will be incorporated into a position paper to be released by early July, marking the start of the JCAHO's attempt to tackle the broader issues, Wise said. In the meantime, the commission identified ways to make a dent in the problem by proposing a new accreditation standard to protect patients placed at risk by ER overcrowding, he said.
But hospitals already trying to resolve the problems of getting patients seen and moved through the ER are constrained by complicating factors over which they have little control, particularly the nursing shortage, Nielsen said. In an AHA survey released in April 2002, 38% of respondents said the nursing shortage was a cause of overcrowding, and 25% said it was a factor in diverting emergency patients from an ER with no room for more.
Management of patients within the ER and in coordinating admissions to free up emergency beds would benefit from information systems dedicated to those purposes, but larger problems of inadequate reimbursement make capital for those systems scarce or unavailable, Nielsen said. Financial and legal problems caused by government payment policies and rising malpractice costs have led to physicians refusing to take Medicare and Medicaid patients and cutting back on new patients, which send more people to the emergency room for care, he said.
All those problems are funneled into "the one last resource, which is the ER, that people turn to," Nielsen said.
Coordination with community services to ease the overcrowding is hampered by the same problems with capacity at nursing homes and home-care agencies, he said.
A new set of requirements affecting a hospital's accreditation only will add to the burden of hospital managers already tapped out trying to hold things together, Dixon said. "It looks good. It looks like the Joint Commission is really the patient advocate, but I would challenge them to show how this would really improve patient care."
The purpose was to get hospital executives more involved and aware of ways they can improve the situation through better monitoring and management, Wise said. For example, temporary beds for ER patients waiting for inpatient admission should be near the nursing unit to which they're headed instead of the emergency department, so that they are close to the equipment and nurses specially equipped for a certain acute problem rather than an overstressed ER staff with many different types of problems to manage, he said.
Discussions with charge nurses while researching the areas for standards also turned up the need to get a better handle on what beds are empty in inpatient areas, Wise said. Some nurses said they were told the hospital was full but found empty beds when they took a tour of hospital units, he said.
Public comments could change the direction of the standard proposal, however. "We're interested in putting in standards that are doable and make sense," he said. Though the original announcement on May 9 said the effective date for the standard was January 2004 if the JCAHO board approves it, Wise said accredited organizations likely would not be responsible for meeting the requirements for accreditation purposes until January 2005.