[In response to “ED Overcrowding ” by Anton Helman, MD, CCFP(EM), FCFP (Nov. 2019)], the case of Brian Sinclair would indeed be dramatic were it not for the fact that this has happened in other emergency departments all over the world. Let me be clear: There are indeed known solutions to the problem of ED crowding. Implementing all the CQI and Lean efforts within the ED do not solve this problem; they are diversions from the real problem. We are, in effect, “polishing shiny toys” to show we’re doing our part. These efforts, however, create an impediment to real solutions by creating an expectation that yet one more internal solution can solve this problem. Thus, we put providers at triage, implement guidelines, and blame ourselves. You have delays in radiology reads? Well, order fewer tests. You have too many admissions? Admit fewer. In short, only when the ED is “perfect” and has polished all the shiny toys will there be pressure outside the ED. So, go at it.
There are three known solutions that increase capacity and reduce boarding: smoothing of electives, early discharges, and increasing the number of weekend discharges. The full capacity protocol is a “failure” protocol to be used in times when beds can’t be found. Not only do these solutions work, but they ultimately benefit patients, staff, physicians, and the financial health of the institution. In one institution, smoothing resulted in a $130 million improvement in the bottom line with elimination of boarding. In another institution, enhancing weekend discharges not only reduced boarding from an average of 30 patients to zero, but was so effective that a 30-bed inpatient unit was closed; this effort represented a $70 million positive improvement for the hospital. Discharge before noon at one institution dropped their O/E by 0.8, which represents a massive financial gain. I mention the very substantive financial gains because “something terrible will happen to a patient” sadly and obviously hasn’t rung anyone’s bell.
If these things are so effective, why aren’t they done everywhere? Notice that the trio of solutions to improve capacity requires a change in physician behavior. The physician doesn’t have to work harder (in fact, their job becomes easier), they just have to work differently.
So, who’s going to make them? That’s where the solutions fall apart. Successful institutions have all been characterized by strong leadership, leadership that demanded these changes and kept at it until there was success. One should ask, Why are there so few of them?
If you’re working in a place where they’re “working on it,” meeting about it, looking at data every month to see if things change, and suggesting another project for the ED to take on as the problem of boarding continues to worsen—well, welcome to our world. When CMS, The Joint Commission, or your health department comes to visit to assure that safe care is being rendered and has to squeeze by the patients in your hallways in the most obvious of unsafe circumstances, and you receive a citation for a fire extinguisher past its expiration date—well, welcome to our world.
(Asa) Peter Viccellio, MD, FACEP
Stony Brook, New York