Anticipate and Address Variability to Manage ED Overcrowding

Disease outbreaks and mass casualty events as well as scheduled variability (eg, diminished consultant availability on weekends) can cause enormous variability in hospital bed demand. Some of this variability is highly predictable.²³ The resultant surges in patient care needs can be managed by hiring a 24-hour ED flow director who is accountable for ED overcrowding, day-ahead demand-capacity matching throughout the hospital, twice-daily multi-unit bed meetings, accountable care unit strategies, and smooth scheduled variability planning.²⁴ The individual physician must develop a “higher gear” as needed and model this for trainees and colleagues.

ED overcrowding should be understood by all health care professionals, administrators, and politicians to be a systemwide problem with accountability on every level, from individual emergency physicians to government officials. We should make every effort to help improve ED overcrowding. This applies both to our clinical practice and to taking on leadership roles that can affect change at the hospital and government levels. If we all adapt this mindset, I have confidence that the ED overcrowding problem will be solved.

Special thanks to Dr. Grant Innes, Dr. Howard Ovens, and Dr. Samuel Campbell for their expert contributions to the podcast that inspired this article.

References

1. Gerster J. Brian Sinclair: a man was ignored to death in an ER 10 years ago. It could happen again. Global News. Sept. 21, 2018. Accessed Oct. 24, 2019.
2. Singer AJ, Thode HC Jr., Viccellio P, et al. The association between length of emergency department boarding and mortality. Acad Emerg Med. 2011;18(12):1324-1329.
3. Spirvulis PC, Da Silva JA, Jacobs IG, et al. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust. 2006;184(5):208-212.
4. Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust. 2006;184(5):213-216.
5. Sun BC, Hsia RY, Weiss RE, et al. Effect of emergency department crowding on outcomes of admitted patients. Ann Emerg Med. 2013;61(6):605-611.e6.
6. Bond K, Ospina MB, Blitz S, et al. Frequency, determinants and impact of overcrowding in emergency departments in Canada. Healthc Q. 2007;10(4):32-40.
7. Derlet RW, Richards JR. Emergency department crowding in Florida, New York, and Texas. South Med J. 2002;95(8):846-849.
8. Kulstad EB, Kelley KM. Overcrowding is associated with delays in percutaneous coronary intervention for acute myocardial infarction. Int J Emerg Med. 2009;2(3):149-154.
9. Liu SW, Chang Y, Weissman JS, et al. An empirical assessment of boarding and quality of care: delays in care among chest pain, pneumonia, and cellulitis patients. Acad Emerg Med. 2011;18(12):1339-1348.
10. Kulstad EB, Sikka R, Sweis RT, et al. ED overcrowding is associated with an increased frequency of medication errors. Am J Emerg Med. 2010;28(3):304-309.
11. Liew D, Liew D, Kennedy MP. Emergency department length of stay independently predicts excess inpatient length of stay. Med J Aust. 2003;179(10):524-526. 
12. Pines JM, Pollack CV Jr, Diercks DB, et al. The association between emergency department crowding and adverse cardiovascular outcomes in patients with chest pain. Acad Emerg Med. 2009;16(7):617-625.
13. Tekwani KL, Kerem Y, Mistry CD, et al. Emergency department crowding is associated with reduced satisfaction scores in patients discharged from the emergency department. West J Emerg Med. 2013;14(1):11-15.
14. Medley DB, Morris JE, Stone CK, et al. An association between occupancy rates in the emergency department and rates of violence toward staff. J Emerg Med. 2012;43(4):736-744.
15. Innes GD, Sivilotti MLA, Ovens H, et al. Emergency overcrowding and access block: a smaller problem than we think. CJEM. 2019;21(2):177-185.
16. Schull MJ, Kiss A, Szalai JP. The effect of low-complexity patients on emergency department waiting times. Ann Emerg Med. 2007;49(3):257-264,264.e1.
17. Innes GD. Sorry—we’re full! Access block and accountability failure in the health care system. CJEM. 2015;17(2):171-179.
18. Howell E, Bessman E, Kravet S, et al. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149(11):804-811.
19. White AL, Armstrong PA, Thakore S. Impact of senior clinical review on patient disposition from the emergency department. Emerg Med J. 2010;27(4):262-265,296.
20. Li CJ, Syue YJ, Tsai TC, et al. The impact of emergency physician seniority on clinical efficiency, emergency department resource use, patient outcomes, and disposition accuracy. Medicine (Baltimore). 2016;95(6):e2706.
21. Campbell SG, Innes GD, Magee KD, et al. A five-step program for diagnostic test addiction. CJEM 2019;21(5):576-579.
22. Schechter MT, Sheps SB. Diagnostic testing revisited: pathways through uncertainty. Can Med Assoc J. 1985;132(7):755-760.
23. Morton MJ, DeAugustinis ML, Velasquez CA, et al. Developments in surge research priorities: a systematic review of the literature following the Academic Emergency Medicine Consensus Conference, 2007-2015. Acad Emerg Med. 2015;22(11):1235-1252.
24. Litvak E, Fineberg HV. Smoothing the way to high quality, safety and economy. N Engl J Med. 2013;369(17):1581-1583.