Unsustainable ED crowding grows twice as fast as visits

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Emergency department crowding is growing twice as fast as visits and will rise to unsustainable proportions, according to Jesse Pines, director of the Center for Healthcare Quality at George Washington University and associate professor of emergency medicine and health policy in Washington, D.C.

ED visits increased 60 percent faster than population growth over an eight-year period. Crowding, or occupancy, as it's called, grew even faster, according to an Annals of Emergency Medicine study published online Tuesday. While ED visits increased by 1.9 percent annually from 2001 to 2008, crowding grew by 3.1 percent.

"Visit volume is going up, which is outpacing population group, and patients are staying longer and longer within the ED getting more intense work-ups and treatments," Pines said in a statement to FierceHealthcare. "Together, the 'occupancy,' which is the number of patients in our nation's emergency care system at one time, is rising at a very rapid, unsustainable rate."

Although advanced imaging often receives much of the blame for delays in the ED, researchers found that it had more to do with practice intensity, that is, blood work and x-rays at triage, that's really bogging down the ED.

Patients are getting more tests, fluids and procedures for a number of reasons, Pines explained. Some providers are practicing defensive medicine, but patients and providers also expect high-technology care, such as requiring CT scans or other advanced test before admitting the patient to the hospital.

"As technology outside the ED improves, such as organ transplantation and cancer care, when patients have complications--and they do--they end up coming in and are sicker and need more ED resources to take care of them," Pines said about the older, sicker population.

Even more, EDs have become rapid diagnostic centers. For example, patients who need X-rays will go to the ED because it's the fastest place to do it, especially when their physicians refer them there, Pines said.

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"The 'occupancy,' which is the number of patients in our nation's emergency care system at one time, is rising at a very rapid, unsustainable rate."

--Jesse Pines, director of the Center for Healthcare Quality at George Washington University
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"Lengthy work-ups in the emergency department are not always a bad thing if they prevent a costly hospitalization. The problem is that more and more demands are being placed on emergency departments and the mood in the health policy community is to shrink emergency departments, not grow them," Pines said in a research announcement.

Providers can help patients early in the care process, trimming off wasted time in the waiting room. For instance, hospitals can place a physician at triage or eliminate triage altogether when there are empty rooms.

In addition, facilities can use space better to meet patient demands. When the ED is full, patients can wait in the ED, as opposed to outside of it in the waiting room, for tests to be completed.

And lastly, much of the way that ED crowding should be avoided is pinching it off at the source and preventing ED visits altogether with public health measures so patients don't get sick or allowing patients to get "sick visits" at their doctor's office, Pines noted.

For more information:
- here's the research announcement
- see the study (.pdf)

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