The recent uproar over the Joint Commission's proposed standard to reduce emergency department overcrowding may obscure one fact: Both sides are right.
The effort aims to hold hospitals accountable for trying to alleviate the problem (May 19, p. 6). In response, industry leaders point to a host of social and workforce factors, such as the rising number of uninsured and a nursing shortage, that drive overcrowding and are outside of hospitals' control. Let's take a closer look.
In recent years, America's emergency departments experienced longer and longer backups as the number of visits has increased and the number of departments has dropped. From 1992 to 2001, emergency department visits in America increased 20% while the number of departments dropped 15%. An April 2002 survey by the American Hospital Association showed that 62% of all hospitals reported being at or over capacity. Perhaps most poignantly, there are daily media reports of patients traveling extra miles or waiting extra hours because of hospital diversions or backed-up waiting rooms. This issue resonates strongly with Americans who have become accustomed to viewing the emergency department as the place where all can go and receive care 24-7. And we all wonder how this system could possibly cope with a bioterror disaster.
The forces driving these trends are not so easy to articulate. They are complicated and require a range of responses. Hospitals are right when they say much of the problem is caused by social issues they cannot solve. The healthcare safety net is in disarray. A lack of primary care and specialist access in many communities, rising numbers of uninsured, nursing shortages and a lack of capital make it harder for hospitals to have the emergency department and inpatient capacity to handle the onslaught.
Other changes have worsened this problem. Physicians now are more likely to view the emergency department as a diagnostic center or someplace to refer their ambulatory patients after hours. The economics of these practices have led many specialists to resist taking emergency department calls, creating longer delays and bottlenecks. Meanwhile, hospitals have downsized the inpatient enterprise, including critical-care capacity, in response to managed care. They are ill-equipped to deal with rising demand. Full inpatient units often translate into patients boarding in the emergency department and hospitals trying to divert patients elsewhere. None of this will be fixed until we're willing to make the required investments in healthcare and the safety net.
But it still is hard to argue that hospitals can do nothing. In our Robert Wood Johnson Foundation-funded initiative (available at urgentmatters.org) we set out to create and foster innovation in emergency departments and hospital patient flow in select hospitals, while understanding the problems many hospitals confront that are outside of their direct control. We visited dozens of hospitals across the nation and collected data on several hundred. What we found surprised us. Some hospitals do a very good job of handling patient flow through the emergency department and the inpatient side. Unfortunately, many do not.
In many institutions, emergency department backups and bed logjams are viewed as daily headaches, peaking in the evening and "solving" themselves by the next morning. These are viewed as unavoidable random problems rather than predictable issues. Senior management generally is not even present when the department overflows at night. The handoff of patients from the emergency department to inpatient units is a relatively casual process, with little effort dedicated to predicting demand for emergency services and inpatient beds. The most common response is to go on "divert" or bypass. This is increasingly a meaningless intervention in many communities as everyone else also has gone on bypass or the practice is prohibited by local authorities.
Hospitals that have made headway on emergency department overcrowding understand that it is driven more by variables outside the department rather than within it. They have the commitment of individuals at all levels and parts of the organization to the ideas of measuring and improving patient flow. Nurses in the inpatient units and emergency departments work as a team to ensure inpatient beds are quickly freed up when needed for admitted emergency patients. The medical staff embraces the need to discharge patients first thing in the morning. Simple systems are in place to make sure that the myriad services that the emergency department depends upon are performed quickly (such as laboratory tests and X-rays). Staff is empowered to make rapid changes in response to changing conditions. Perhaps most important, the critical variables and outcomes across the institution actually are measured. All of this happens in an environment in which senior management views patient flow as a priority, not a problem.
Understandably, some institutions may be reluctant to further "open up" their emergency departments. They fear that more visits may mean more uncompensated care. Viewed narrowly from the department's perspective this may be so, but overcrowding often is driven by gridlock in the inpatient units. In our work we saw many hospitals unable to admit paying, high-margin cases because they lack available inpatient capacity.
Reasonable people can argue the merits of the standards being promulgated by the Joint Commission on Accreditation of Healthcare Organizations. But the social issues driving emergency department overcrowding won't be fixed anytime soon. Given these facts, it will fall to hospitals to do the most they can to make this the best possible situation for their patients.
Bruce Siegel is a professor of health policy at George Washington University, Washington.