Top 10 issues in hospital medicine for 2006---issue 3: emergency department crowding

ER crowding seems to have reached a crisis level this year, attracting the attention of the Institute of Medicine and the medical blogosphere. The problem is well illustrated in a recent newspaper article from Arizona linked by Grunt Doc.

What’s the solution? The late medical humorist and author Robert Eliot, M.D. was fond of telling the joke about a man who cut his finger with a kitchen knife and went to the ER. After going through the main entrance he came upon two doors. The sign over one door said “critical” and over the other door “stable.” He went through the door marked “stable” and down a long corridor before coming to another set of doors, one of which was marked “illness” and the other “injury.” After going through the “injury” door he came to another set of doors, one of which was marked “blow” and the other “cut.” He examined at his finger, decided that the injury was indeed a cut and went through the appropriate door. The next pair of doors was marked “extremity” and “torso.” He opened the door marked “extremity”, walked down a corridor and found two doors marked “bleeding” and “not bleeding.” Because the bleeding had stopped by this time he went through the door marked “not bleeding” and found himself in the parking lot. Good case management?

Equally humorous was the Institute of Medicine’s solution recently published in the New England Journal of Medicine which said, in effect, “hospitals: cease patient boarding and ambulance diversion by just being efficient.” What’s humorous and patently absurd about this mandate is that hospitals have been under maximum pressure to improve efficiency and patient flow for 23 years. Thanks to the prospective payment system (DRGs) implemented in 1983 their very survival already depends on efficient patient flow. My previous post criticizing the Institute of Medicine is here. More critical commentary on the IOM recommendation can be found at DB’s Med Rants and Kevin M.D.

Hospitals can cut down on ambulance diversion with aggressive bed control strategies, but busy hospitals have not been able to eliminate it. St. Louis University, for example, despite intensive process changes geared specifically toward the problem, still diverts ambulances on average between 30 and 60 minutes a day.

Hospital administrators, reluctant to divert ambulances, sometimes allow their ERs to accept patients even when all inpatient beds are occupied. This results in worsening of crowded conditions since patients in need of admission have no place to go and must be “boarded” until an inpatient bed becomes available. Such boarding can take place wherever space happens to be available such as hallways, one day surgery or observation units or the ER itself with the location determined in many cases by staffing. In some states, however, regulations may dictate where patients can be placed.

Dealing with such conditions requires a spirit of cooperation and a seamless relationship between the ER and the rest of the hospital. Unfortunately, if some of Grunt Doc’s commenters or a recent thread over at the UCSF Emergency Medicine Listserve are any indication there is a culture of finger pointing, an “us against them” mentality which will prove counter productive to any solutions for ER crowding. I commented about this culture of blame here.