Emergency Room Overcrowding: How Far Have We Come?

Introduction

The emergency department room sometimes called the emergency room (ER), emergency ward (EW), accident & emergency (A&E) section or known as casualty department is a hospital or primary care department that provides initial treatment to patients with a broad range of illnesses and injuries, some of which may be severe and require immediate notice. Emergency departments urbanized during the 20th century in response to a greater than before need for brisk appraisal and administration of grave illnesses. In some countries, emergency departments have become vital entry points for those without other means of admittance to medical care.

Upon entrance in the ED, people usually undergo a brief triage or sorting, interview to help decide the nature and sternness of their illness. Individuals with serious illnesses are then seen by a physician more rapidly than those with less severe symptoms or injuries. After initial assessment and treatment, patients are admitted to the hospital, stabilized and transferred to another hospital for a variety of reasons, or discharged.

The staff in emergency departments not only includes doctors, but physician assistants (PAs) and nurses with specialized training in emergency medicine and in house emergency medical technicians, respiratory therapists, radiology technicians, Healthcare Assistants (HCAs), volunteers, and other support staff who all work as a team to treat emergency patients and provide support to nervous family members.

Micah (1995) said “The emergency departments of most hospitals operate around the clock, although staffing levels are usually much lower at night. Since a diagnosis must be made by an attending physician, the patient is initially assigned a head complaint rather than a diagnosis” This is usually a symptom: headache, nausea, loss of awareness. The chief complaint remains a primary fact until the attending physician makes a diagnosis.

The major Implications for choice Makers some medical centers have been coping with serious problems of emergency room overcrowding for several years. In 1995 the Regional Board launched a major reorganization of healthcare services. This initiative called for closing several short-term care hospitals and for a major shift to ambulatory services. The study shows the following effects in emergency rooms: The organization of community services was unable to adapt to the changes in the healthcare system, and this contributed in part to a constantly increasing volume of patients in emergency rooms. Despite a major rise in hospital productivity, access to hospital beds became increasingly limited for emergency clients. The sharp cuts to beds and staffing levels are restricting access to hospital resources.

The average length of hospital stays, which had leveled off in hospitals that had begun the shift to ambulatory care at an earlier date, began to rise with the increase in hospital clientele. Clinical and management practices in participating hospitals have become more standardized, as evidenced by the narrowing of differences between hospitals in the length of stays and use of emergency rooms. Differences in length of stays between general and highly specialized hospitals are mainly due to differences in the composition of their clientele. • Some hospitals have a safety margin of too few beds to respond to fluctuations in demand.

Executive Summary Quebec, and the Montreal area, in particular, has been coping with chronic overcrowding in emergency rooms for several years. In 1995 the Regional Board launched a major reorganization of healthcare services in Montreal. This initiative called for closing several short-term care hospitals and for a major shift to ambulatory services. This research was designed to comprehend the impact of the shift to ambulatory care on the changing situation in emergency rooms.

The issue was approached from two angles: To what extent have measures been implemented to manage ambulatory care in hospitals? • • What is the impact of the level of realization of ambulatory care on the evolution of the use of hospital beds and emergency room gurneys? The consequences The study highlights the major efforts made by participating hospitals in recent years to implement the shift to ambulatory care, as well as the benefits of this shift for improved hospital productivity. However, the effects of improved hospital productivity on changes in the length of gurney patient stays are inconclusive. The constantly increasing volume of patients appears to be partly the result of growing problems of access to community services, for which the organization was unable to adapt to the changes in the healthcare system.

Here is what Andrew (2005) said” The implementation of measures upstream and downstream from emergency rooms —such as homecare services or integrated services for vulnerable clients—is likely to reduce reliance on emergency services. The study implies that access to hospital beds is becoming increasingly limited for emergency room clients. In the context of budget cuts, it is important to examine the scope and consequences for patients of under-use of short-term care beds” The average length of hospital stays, which had leveled off in hospitals that had begun the shift to ambulatory care at an earlier date, has begun to rise.

This trend is partly attributable to the increase in hospital clientele. Similar changes are anticipated in hospitals that began the shift to ambulatory care more recently. Finally, clinical and administrative practices in participating hospitals have become more standardized, as evidenced by the narrowing of differences between hospitals in the length of stays and use of emergency rooms. The narrowing differences between hospitals in the length of stays in hospital and emergency rooms suggest the emergence of a measure of evenness of clinical and management practices in participating hospitals. Differences in length of stays between general and highly specialized hospitals are mainly due to differences in the composition of their clientele.

Here is what Spencer (2002) said “Findings All participating hospitals have implemented the shift to ambulatory care. Some institutions, however, have made most of their efforts before or around the announcement of the reconfiguration plan. For all the hospitals studied, we found a reduction in length of stays and an increase in outpatient care. This situation has specifically resulted in an increase of clientele for care units and a rise in hospital productivity” The study revealed the impact of additional budget constraints imposed on hospitals as part of government policy to eliminate the deficit.

This policy resulted in a reduction of the pool of short-term care beds and affected some institutions more than others. Productivity rose in all hospitals, as more was done with fewer resources. However, assuming optimal use of beds available in the hospitals studied, some have little or no margin of safety to cope with fluctuations in demand. We noted a continuous, steady growth in the volume of gurney patients in the emergency rooms of all hospitals throughout the observation period. Hospital closings had less impact on the observed trend in changing patient volumes. As a result, the hospitals that remained open had to absorb this growth in volume despite cutbacks in the number of gurneys and beds in the region. Hospitals that took over from or were near the closed hospitals were only temporarily affected by the closures.

The average length of stay for gurney patients in emergency rooms has declined but these gains were made before the reorganization was announced, regardless of the initial level of overcrowding. The research findings, therefore, do not identify a clear pattern in the links between hospital productivity and the changing length of stays by emergency room gurney patients. However, the reversal in the trend toward longer average stays by gurney patients in recent years is a concern.

In fact, despite earlier progress on the length of stays, hospital emergency rooms have been experiencing growing difficulty absorbing the nonstop, steady rise in the volume of gurney patients. Approach This is a multiple-case study with time series spread over seven years. Six hospitals in the Montreal-Centre region were selected based on: Their proximity to or designation to take over from a closed hospital The extent of overcrowding in their emergency room between 1991 and 1994 execution was carried out through a survey and semi-structured interviews of managers at participating hospitals.

Various sources of administrative data were also used to document changes in: Use of beds and gurneys Availability of beds in participating hospitals All the information gathered was presented in monographs and a cross-analysis was conducted to verify replication of explanations. ARIMA models were used to analyze the change in use of gurneys based on the information contained in the emergency room register

I Further research The study stresses the importance of developing a standard method for counting beds that factors in real-time bed closures as well as a computerized bed management tool to support adequate management of available resources.

The findings show that emergency room clients have increasingly limited access to hospital beds. The scope of this merits study to improve our understanding of whether or not — and to what extent — emergency rooms are used as a substitute for hospitalization, and of the consequences for patients of under-utilization of hospital resources. Finally, we propose to study those new methods of organizing services (for example, incorporated service networks for chronic patients and elderly clients, groups of family physicians, methods for articulating services between emergency rooms and the community) that help reduce reliance on emergency rooms.

Spencer (2002) said “The nation’s nearly 4,000 hospital emergency rooms are operating at critical capacity. ERs provide an essential health care safety net for people unable to obtain medical care elsewhere.

ERs provide an essential community service, providing medical care to 44 million low-income Americans with no or limited health insurance.

Emergency room overcrowding is one of the biggest issues facing hospitals nationwide. An American Hospital Association study released early in 2002 found that 90 percent of large hospitals’ ERs were at or over capacity, and 60 percent of hospitals felt they were filled and could not easily accommodate additional patients”

Some of the reasons for ER overcrowding include looser management of care by HMOs, Medicare, and health plan cutbacks, stricter enforcement of EMTALA (Emergency Medical Treatment and Active Labor Act), more uninsured patients seeking care in the ER, fewer ERs overall nationwide, the health care worker shortage, population growth, sicker patients and a growing senior population segment.

The Centers for Disease Control and Prevention’s National Center for Health Statistics conducts an annual survey of visits to the ER as part of its National Health Care Survey, which also covers doctors’ offices, hospitals, nursing homes, hospices, and home health care. The CDC released in 2002 a national report on ER visits (data from 1997-2000), indicating that there were 108 million visits in 2000, up 14 percent from 95 million visits in 1997. Because the number of hospitals providing emergency care decreased from 4,005 to 3,934 between 1997 and 2000, the number of annual visits per ER has amplified about 16 percent since 1997 from 24,000 to 27,000, and waiting time for no urgent visits has increased 33 percent. No urgent cases are defined as those patients who should be seen between two and 24 hours of arrival.

The lack of affordable liability insurance threatens the ability of many physicians to practice medicine, potentially leaving patients without access to medical care.

Uncompensated care is causative to a growing crisis in the nation’s hospital ERs, often “providers of last resort” for people with no other access to medical care – the poor, the uninsured, certain minority groups, and rural residents.

While most physicians’ offices collect about 85 percent of their fees, ERs collect only about 50 percent. This uncompensated care can result in increased charges to people who can pay, although many payors, such as Medicare and HMOs, pay only fixed or discounted amounts. As a result, many hospital ERs are operating in the red, jeopardizing their ability to operate.

Everyone who comes to an ER will be seen, regardless of his or her ability to pay or insurance status.

According to the American College of Emergency Physicians, patients with no urgent problems are not causing the overcrowding crisis. However, many industry experts see the trend as an emerging problem, complicating an already vulnerable situation in the nation’s ERs.

Andrew (2005) said “Not only is ER overcrowding an issue of superiority patient care and patient satisfaction, it has become the focus of accrediting and governmental agencies. The Joint Commission on Accreditation of Healthcare Organizations recently released for public comment a proposed standard to address ER overcrowding. The draft standard calls on hospitals to resolve what JCAHO said is a growing crisis that puts patients at high risk of treatment delays or inadequate care. If approved, the proposed standard will go into effect “

Here is a report from Washington: WASHINGTON (AP) — The American Hospital relationship reported its national survey found that one in three emergency rooms are so crowded that ambulances are sometimes diverted to other hospitals.

According to David(1999)”The problems are most acute at large, urban hospitals. The vast majority of these emergency rooms said they were operating at or over capacity, and more than half of them diverted patients for at least an hour in November 2001.

“Emergency department overcrowding itself is a symptom. It’s a symptom of a health care system that’s broken,” said Carmella Coyle, senior vice president for policy at the American Hospital Association, which lobbies on behalf of hospitals for increased federal funding and other priorities.

The problem runs throughout the system, with backed-up hospitals reporting longer waits to move patients into hospital beds and longer stays inside the emergency departments. The strains on capacity translate into longer waits for treatment, the survey found. The average waiting time for treatment at an emergency room operating at congestion was more than an hour, compared with 39 minutes at hospitals reporting a good balance of patients to capacity.

Part of the problem may be the amount of time it takes to move a patient into a hospital bed. At overcapacity emergency rooms, the average wait for an acute or critical care bed was 4.6 hours in November and about the same for a psychiatric bed. The wait was just 2.2 hours for each at hospitals reporting a good balance”

As a result, patients are staying longer in the emergency department. At those operating at or over capacity, the average stay was 3.7 hours, compared with just 2.5 hours at hospitals reporting a good balance. The longer stays in emergency rooms may also explain the long waits, Coyle said.

According to Micah(1995)”The survey asked hospitals to keep track of activity in their emergency departments during November 2001. The definition of “at” or “over” capacity was left to each hospital. The survey found:

  • Overall, 34% of all hospitals surveyed reported that they were operating over capacity. Another 28% said they were operating at capacity.”
  • Nearly half of urban hospitals were operating over capability and another third were at capacity, the survey found. Among the largest hospitals, those with 300 or more beds, 61% were over capacity and nearly one in three were at capacity.
  • The difficulty appears to be most acute in New England, where 52% of hospitals say they are at overcapacity, and on the West Coast, where 44% reported the same.

References

David,.O: Challenges of the emergency room.Pitssbug Press.Califonia. 1999.

Spencer, A: Managing Emergency Room over Crowding. Atlanta Press. 2002.

Micah and Bruno.Theoritical Complications of the emergency room: Fact and figures New line Publishing Press. 1995.

Andrew, P: The problem with emergency overcrowding: Handling emergency over crowding. Edwin Press Company. 2005.