ED Overcrowding a Patient Safety Issue

John Commins, for HealthLeaders Media, December 10, 2008

A new study that surveys 3,562 emergency department clinicians in 65 hospitals across the nation raises concerns about the safety of critically ill patients who are parked in hallways and denied timely care in overcrowded emergency departments.

The study's lead author, David Magid, MD, an emergency physician and a senior scientist at the Kaiser Permanente Colorado Institute for Health Research, says emergency department clinicians are reporting widespread problems in four systems that are critical to ED safety: physician environment, staffing, inpatient coordination, and information coordination and consultation.

"Prior studies have shown that emergency departments are overcrowded. Our study was the first to closely examine the safety from the perspective of the clinicians who actually work in the emergency department, including physicians and nurses," Magid tells HealthLeaders Media. "We found the same results in small hospitals and large hospitals, the same results in community hospitals and academic hospitals, and we found the same results in hospitals in every area of the country."

In the study, 25% of clinicians say their ED is too small, 32% say the number of patients exceeds their ED's capacity to provide safe care most of the time, and 50% say their patient capacity is exceeded some of the time. Fewer than half of ED clinicians say that most specialty consultations for critically ill patients occur within 30 minutes of being contacted. Half of the clinicians report that ED patients requiring ICU admission are rarely transferred from the ED to the ICU within one hour.

"What our study does say is that we need greater investments in the larger emergency care system and we need more investment at the hospital level. We need hospital leaders and administrators to step up and make additional investments," Magid says.

The study is funded by the Agency for Healthcare Research and Quality and published online in the Annals of Emergency Medicine.

When ED patients are parked in hallways, Magid says, they are frequently denied or delayed access to the specialized services, supplies, monitoring equipment, and privacy that would be found in a dedicated ED treatment area.

The demand for emergency department services has increased by 26% over the past decade, even as the number of EDs in the nation has decreased by 9%. And Magid's study was compiled before the national economy tanked this fall. "With the numbers of people losing their jobs and likely losing their health insurance, as well as employers and people who are employed reducing their health insurance coverage, it is certainly possible that this could drive up the number of ED visits, which would only exacerbate the problem that we were already seeing in the study," Magid says.

Any coordinated national solution to address ED overcrowding will have to involve the federal government, Magid says. But he says there are also measures that individual hospitals can take. "I would tell them to increase or redesign their emergency department space so it can handle greater capacity of patients," he says. "I would suggest increased staffing during periods of high demand. And I would suggest they increase access to health information technology by providing more computer work stations and access to electronic health records that can be easily accessed by emergency department clinicians."

Magid's not sure what impact his study will have. After all, ED overcrowding has been widely reported in the news media, and has been the subject of numerous prior studies over the past few years. But the problem persists.

"I can't emphatically say that people aren't working on this problem already. But to the degree that they are, we need increased effort and new solutions," he says. "Hopefully, results of studies like ours, which go beyond merely showing that the ED is crowded to showing the impact crowding is having on safety issues, might motivate people to do more."

What will it take to get that message through to hospital administrators?

"The best people to ask that question are hospital administrators," Magid says.

John Commins is the human resources and community and rural hospitals editor with HealthLeaders Media. He can be reached at jcommins@healthleadersmedia.com.
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