Boston - No, it was not a Red Sox game. It was a conference sponsored by the journal Academic Emergency Medicine, and the subject was providing high-quality care in the crowded emergency department.
If you've been healthy and careful, you may not know that emergency departments are often crowded. Good for you. If you have been less fortunate, you may be all too keenly aware of how crowded they often are and how challenging the doctors and nurses find it to provide the best possible patient care under those conditions.
The causes of crowding are obvious to those who spend their working lives in the ED. But to everyone else, maybe less so.
So here is a primer. Crowding means the number of patients is high relative to the available resources (especially physical space) to care for them. That can happen because of (1) inflow; (2) how long it takes to evaluate and treat a patient; and (3) outflow.
The first factor is straightforward. When many patients arrive, we may quickly run out of places to put them. There are emergency departments that simply don't have enough space for the number of patients seeking care, often because that number has risen quickly over a relatively short time and the hospital has been unable to adapt. But any ED can get crowded because of high inflow as a short-term problem during periods of peak demand, such as a difficult flu season.
The second factor is commonly referred to in the industry as "throughput." Some patients require evaluation and treatment that is time-consuming. And some processes consume more time than others. Certain diagnostic tests can take hours, although there is often room to improve "turnaround time" for some of them.
The third factor, one that accounts for a large part of crowding, is an outflow problem. This used to be an important factor mostly at large, urban hospitals, but it has become more widespread in the last ten years. When it is determined that a patient requires hospitalization, the patient is supposed to go upstairs. But suppose there are no beds available upstairs? The patient is "stuck" in the ED - for hours, or even days. This is called "boarding." When admitted patients board in the ED, that occupies beds. Not necessarily rooms, but beds. You see, boarded patients sometimes get moved into any available space, including hallways. There are EDs in which this is an everyday situation, and the number of patients lying on gurneys in hallways waiting for inpatient beds exceeds the number of ED patients undergoing their initial evaluation and treatment.
You can easily imagine how being a boarder is a bad thing. You are competing for nursing attention with the new patients. The doctors are busy evaluating and treating the new patients and may think of you as being no longer their responsibility, as if you were upstairs even though you aren't. The nurses taking care of you are accustomed to taking care of ED patients, not inpatients, and so your needs are not part of their usual scope of practice. The growing scientific literature on this subject in the emergency medicine journals tells us that boarded patients have worse outcomes: there are more errors in their treatment, including serious ones, their total length of stay in the hospital is longer, and they are more likely to wind up in a nursing home after hospitalization. They are also more likely to die.
If you are a patient in an ED with boarding but you are not one of those unfortunate boarders, you are still in a bad place, so to speak, because the staff attending to your needs may be overwhelmed by the additional demands being placed upon them.
The American College of Emergency Physicians has published the report of a task force that details high-impact, low-cost solutions: things hospital managers can do to improve the efficiency of utilization of existing institutional resources to make inpatient beds available to ED patients in a more timely manner. Ultimately, however, we must face a simple fact: our population is getting older and acquiring more medical problems, and it will take more resources to care for them. There is a shortage of nurses, doctors, and hospital beds. At a time when the number of ED visits has been rising steadily, year after year, the number of hospitals is declining, and the number of EDs is declining even more sharply.
And the people inside the beltway (that's I-495, which approximately makes a circle around Washington, DC) seem to have turned a blind eye and a deaf ear toward this problem. This will get worse before it gets better. If you like to talk to your Member of Congress, make this a topic of conversation.
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