One of the great things about an eight-year study of emergency departments published last month in the Annals of Emergency Medicine is that it challenges some preconceived notions about the problems in EDs these days.
The National Trends in Emergency Department Occupancy report covers from 2001 to 2008, and yes, we know how some of the story goes, with the power of hindsight over the past four years. During those study years, patient visits increased 60% faster than population growth, according to the report.
Ouch. Major overcrowding. Aggravating throughput issues.
Those problems are expected to intensify since the U.S. Supreme Court has upheld the healthcare reform law, guaranteeing that more uninsured will be brought into the system, as far as emergency physicians see it.
And while the court has left it up to the states whether to expand Medicaid coverage, any increase in "the number of patients on Medicaid without an equivalent increase in the number of physicians willing to take that insurance will surely increase the flood of patients into our nation's ERs," David Seaberg, MD, CPE, FACEP, president of the American College of Emergency Physicians, said in a statement this week.
"While there are provisions in the law to benefit emergency patients, it is clear that emergency visits will increase as we have already seen nationwide,"Seaberg added.
Meantime, the crowding continues. Citing a General Accountability Office report, ACEP has stated that emergency patients who need care within one to 14 minutes are not always seen that quickly. For some it takes as long as 37 minutes.
As physicians and healthcare leaders evaluate ED improvements, the trends study is instructive because it delves into the weeds of the past to identify the causes of some of today's overcrowding.
Too many clinical tests and boarding, a pair of issues that often swirl around ED overutilization debates, were among the topics targeted in the report by Stephen Pitts, MD, MPH of the Department of Emergency Medicine at Emory University in Atlanta, GA, and Jesse M. Pines, MD, MBA, of the center for health care quality at the George Washington University Medical Center in Washington D.C.
Researchers found surprises in their evaluation of the data.
While imaging increased tremendously from 2001 through 2008, by 140%, routine tests had more of an overall impact on crowding in the ED, the physicians said in the report. Those tests included giving of intravenous fluids, blood tests, or other routine procedures.
The problem wasn't the time it took to perform the clinical tests and interventions, but the frequency of the tests and treatments, researchers found. While CT scans, MRIs or ultrasonography increased significantly, so did the volume of procedures, such as performing three or more diagnostic tests on single patient and issuing two or more medications.
The frequency and wait times for those patients in the ED increased from 26% to 76%, and the combination of all of the "routine" testing exceeded the crowding and delays wrought by imaging work, they said.
"These are things we do on an everyday basis," Pine told HealthLeaders Media, referring to the routine tests. The impact on ED crowding and waiting "was a surprise," he added.
Ironically, it is possible that innovations intended to speed ED throughput—such as authorizing the early ordering of blood testing, intravenous lines and radiographic testing at triage—may also be slowing down ED operations, Pines says.
All those clinical tests, which the report described as "greater treatment intensity," may reflect several factors, including the practice styles of physicians geared to order more testing, according to Pines. That could be pinned on a variety of issues that could range from docs seeking higher quality care, but also those practicing defensive medicine, or pursuing financial incentives.
Another major problem for EDs has been "boarding" which refers to patients waiting for an ED bed assignment. This is an all-too-frequent phenomenon that is often seen as a culprit in ED occupancy and duration of stay. Hospital officials have been working to relieve the pressure on boarding for years, which has often resulted in ambulances diverted, and critically ill patients traveling farther for care, adding delays to their treatment.
"That was the second surprise," Pines said.
While boarding practices are certainly factors in crowding, they contribute significantly less than "practice intensity," which again includes "more frequent blood testing, greater use of advanced imaging and more frequent administration of intravenous fluids," the study states.
"We hypothesized that increased boarding of hospital admissions in the ED would be the most important cause of increasing levels" of occupancy in the ED, the report states. "This was not the case."
"We found that boarding is important and a big contributor," Pines says. "If you looked particularly at the difference why length of stay was increasing over the eight-year period, it looked like it wasn't boarding going up, it was more practice intensity, taking the lab tests or blood tests. "
In their report, researchers analyzed data from the yearly National Hospital Ambulatory Medical Care Surveys from 2001 through 2008. The surveys abstract patient records from a national sample of hospital EDs.
These days, Pines agrees that hospitals are putting in place procedures to try to reduce boarding "without building new hospital towers." He also noted that while imaging increased dramatically between 2001 and 2008, "it has leveled off" in recent years, he says.
All good signs. But, there's still that one thing, Pines says.
"How can we get doctors to order fewer tests when patients come into the emergency department?" he asks. "That is a much heavier lift."
Joe Cantlupe is a senior editor with HealthLeaders Media Online.
