To Relieve ED Crowding, Stabilize and Mobilize

John Commins, for HealthLeaders Media, October 27, 2008

There is more evidence out there that the best way to relieve Emergency Department crowding is to move stabilized patients out of the ED ASAP, even if it means parking their beds in the hallways upstairs. And that's good news for the nation's cash- and staff-strapped hospitals.

That's what they're doing at Stony Brook University Medical Center on Long Island, where ED Clinical Director Peter Viccellio, MD, says it's not hurting the patients and it's reducing ED crowding. "This is yet another battle cry for hospitals to get off their duffs and stop stacking people knee deep in the emergency department," Viccellio tells the Associated Press.

Viccellio will share his findings with colleagues at a meeting tomorrow of the American College of Emergency Physicians in Chicago.

Not only do crowded EDs represent an aggravating delay, they are also potentially dangerous. An ACEP survey last year of 1,500 emergency physicians found that 13% reported first-hand experiencing the death of a patient because of boarding.

Viccellio's study examined four years of data from more than 2,000 stabilized ED patients at SBMC who were sent to the hallways and found slightly fewer deaths and ICU admissions among the hallway patients than with the standard bed patients, the AP reports.

Of course, hallway patients tend to be relatively healthier in the first place. An ICU patient is not going to be parked in a hallway. But Viccellio's point is well taken and backed up by other studies of ED crowding. The underlying message for EDs should be: Stabilize then mobilize.

This is not a new idea. ACEP has been talking about this for years. In 2007, ACEP formed a task force and told it to find four or five "low cost or no cost" solutions to ED boarding. Tops on the task force's list of recommendations was moving stabilized patients out of the ED and into "hallways, conference rooms, and solaria."

In its report issued this spring, the task force found that "if each hospital unit would care for a small number of additional patients, the burden of boarding would be more evenly spread across the hospital, thus freeing the ED to function effectively without unduly stressing the inpatient units."

In September, another ACEP study found that larger hospitals EDs don't relieve crowding. "While it may seem paradoxical, our study suggests that simply expanding the ED without increasing the rate at which admitted patients move to in-patient beds actually increases the length of stay and boarding times for emergency patients," says Rahul K. Khare, MD, of Northwestern University, the author of the study. Khare likens an ED to a pipe, with the patients passing through like water. "If we enlarge the diameter of the middle of the pipe but leave the end the same, the water actually moves through more slowly. In our simulation, the admitted patient departure rate is the key bottleneck and slows everything else in the ED down."

The thought of having your hospital's hallways, conference rooms, and solaria stacked up with ED patients might conjure up images of a war zone. It's darkly comical to imagine your C-suite conducting meetings around a conference room stacked with patients. It probably would cut down on overly long meetings.

But this is all good news for hospitals. Viccellio's study provides more evidence that relieving ED crowding does not have to involve building larger, expensive EDs with larger, expensive and hard-to-find ED staff, but instead involves the efficient use of all hospital resources—resources that many hospitals already have.

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