Eleven years ago, a 45-year-old aboriginal double-amputee named Brian Sinclair was found dead by ED staff in a Winnipeg, Manitoba, emergency department.1 He had been in the waiting room for 34 hours. A physician had sent him to the emergency department with a referral note later found in his pocket. The cause of death was septic shock secondary to a urinary tract infection.
Explore This IssueACEP Now: Vol 38 – No 11 – November 2019
This is an extreme example of the effect of ED overcrowding on our patients. Yet the literature is rife with stories. There are many known patient-centered consequences of ED overcrowding in addition to increased mortality, including delays in evaluation and essential care.2-9 Overcrowding is associated with more medical errors, increased lengths of stay, worse outcomes, and reduced patient satisfaction.10-13 ED overcrowding may contribute to negative consequences not only for patients but also for clinicians. Overcrowding has been shown to increase stress and exposure to violence for ED staff.5,14
Below, I outline some solutions to ED overcrowding with the hope that, collectively, we can help alleviate the problems of ED overcrowding and improve not only patient outcomes but our work-related stress.
Solutions Must Be Aimed at Hospital-wide Access Block
Many people incorrectly believe that overcrowding stems from high numbers of patients presenting with minor complaints.15,16 In fact, the bulk of ED overcrowding is caused by access block—the inability to transfer patients out of the emergency department to an inpatient bed once their ED treatment has been completed.
The most common bottleneck in the emergency department is the nurse-staffed stretcher, a bed for patients who aren’t able to sit or ambulate and need nurse monitoring. These are often occupied by admitted inpatients in the emergency department. On average, hospitals leave high-acuity patients in emergency department hallways for 46,000 hours per year, resulting in the kinds of deterioration in patient care outlined above. However, this is equivalent to only 1 to 2 percent of inpatient capacity or, on average, 1.5 hours of the total inpatient length of stay. In other words, if inpatient length of stay could be reduced by an average of 1.5 hours, ED hallway medicine and overcrowding would essentially vanish.17
A culture shift in the entire hospital and outpatient services (rather than just the emergency department) that recognizes the impact of hospital-wide efficiency on ED overcrowding is required. Incentives, performance measurements (such as consultant turnaround times), demand-capacity matching, and queue management contingencies for each hospital unit are required to improve hospital-wide efficiency and accountability for overcrowding.18 Each unit will have unique solutions that require innovative thinking and implementation.
But we should lead by example. Emergency departments should be exemplary for the rest of the hospital in practicing accountability for ED overcrowding. One example of a strategy to improve accountability and efficiency of consulting services as well as throughput in teaching hospitals is having a senior consultant resident briefly assess ED patients and make a disposition decision/admitting orders before junior learners serially assess the patient and review with their seniors.19 This may ruffle some academic feathers, so a middle ground would be to implement this strategy at times known to be busy or when ED capacity is approaching critical levels.