Compare this with the harms experienced as a result of crowding, which are often probabilistic (e.g., patients in crowded EDs are at increased risk for delays, but not all patients experience delays), distributed (e.g., in crowded EDs, some patients may experience reduced privacy in hallway beds whereas, others do not), and hard to distinguish from a non-crowded baseline expectation (e.g., harms from a 30-minute delay in antibiotic administration might be invisible to both the patient and the care team).

It appears much easier for people and institutions to justify extraordinary action to address the highly acute, visible, and life-altering harm of the MCI than the pernicious, less visible and sometimes theoretical harm of ED crowding. The ethical underpinnings for this difference, supported by appeals to distributive justice and consequentialism, hold that when health care resources are limited, those whose needs are greatest should receive priority.⁷ In short, the needs of victims of an MCI are generally more acute than the needs of those experiencing ED crowding, and so vigorous plans to address their needs are potentially justified.

Rarity Versus Frequency

A second significant difference is in their relative frequency. It seems difficult for systems to justify extraordinary efforts to ameliorate the supply/demand mismatch of crowding because the mismatch itself is created by the misaligned economics of health care against which hospitals struggle to survive.⁸ Given the rarity of MCIs, extraordinary measures are viewed as feasible to implement whereas for everyday crowding they are not.

The same ethical precept that justifies extraordinary responses to MCIs—that when health care resources are limited, those with the greatest need should be prioritized—also justifies significant responses to crowding. This is because acutely ill or undifferentiated ED patients are generally in more significant need of diagnostic testing and advanced care than other patients who outcompete ED patients for resources, i.e., elective surgical patients for whom inpatient beds are held or inpatients who overstay their need for acute care.⁴

Moreover, although health systems may find it easier to justify extraordinary efforts for MCIs, this does not justify the lack of action to benefit the crowded ED patients—especially as most effective evidence-based strategies to combat crowding are uncomplicated and relatively inexpensive, including off-hours availability of both ambulatory and ancillary inpatient services, smoothing elective admissions and surgeries, inpatient hallway boarding, and active bed management.⁸

Ultimately, we agree that the same moral urgency, operational innovation, and resource allocation that is devoted to MCI response by health systems should also be applied to crowding.⁹ Process changes used to extend ED capacity during MCI events should be implemented continually when the crowding is at a crisis proportion. Algorithms should be developed that help hospital and ED operational leaders know what actions to take based on ED census and need for additional resources, regardless of whether they are caused by an MCI, or other acute influx of ED patients, or the hospital being over its inpatient capacity. MCIs are inherently unpredictable and EDs that proactively manage patient flow across the continuum ensure timely access to resources, including space, equipment, and staff, during acute disasters.