ED Crowding Study

[Guest alsfirefighter]

How about a good study of 911 tie ups while waiting for a stretcher and how about patient dumping by nursing homes of non-urgent calls to 911 because they don't want to wait 20 mins. for a private ambulance.

New CDC Survey Echoes IOM Report

Special EMS Magazine Monthly Insider

A new report from the Centers for Disease Control and Prevention's (CDC) reinforces the assertions of a report on the state of emergency medicine by the Institute of Medicine (IOM) that crowding in the nation's EDs has reached nearly epidemic proportions. 1

The CDC report, based on data from the 2003-04 National Hospital Ambulatory Medical Care Survey (NHAMCS), notes that almost half of U.S. hospitals experience crowded conditions in the ED, with almost two-thirds of metropolitan EDs experiencing crowding at times. About one-third of U.S. hospitals reported having to divert an ambulance to another ED due to overcrowding or staffing shortages at their ED. Crowding in metropolitan EDs was associated with a higher percentage of nursing vacancies, higher patient volume, and longer patient waiting and treatment durations, the report says. Half of EDs in metropolitan areas had more than 5% of their nursing positions vacant. According to NHAMCS figures, the United States had an average of 4,500 EDs in 2003 and 2004, more than half of which saw fewer than 20,000 patients annually. However, one in 10 EDs had an annual visit volume of more than 50,000 patients.

"I think our findings jibe with the IOM's virtually everywhere," says Catharine W. Burt, EdD, chief of the Ambulatory Care Statistics Branch at the National Center for Health Statistics at the CDC and lead author of the report.

Not an aberration

If anything, Burt says, the CDC's report has even greater statistical underpinnings. "A lot of the IOM report was based on some studies about crowding and ambulance diversion done in different states, while this report is national ? saying it's true everywhere, and not just in the places that 'talk' the loudest," she explains.

The validity of national statistics emphasizes that this trend "is not the result of an aberration in Los Angeles, or Massachusetts," Burt says. "The higher your daily occupancy rate, the more likely you are you will have to go on ambulance diversion."

There was one area in which her statistics differed from the IOM's, says Burt, although she is quick to add it doesn't detract from the significance of the problem. In the IOM report, the authors quote a study that found that 91% of hospitals were crowded in the opinion of the ED director, she says.

"But this report is objective: We actually count how many diversion there were, how many left without being seen, and how many urgent cases that should have be seen had to wait longer than an hour on average," Burt says. "Our statistics show that 50% of EDs were crowded ? not 91% ? but it's still a common thing."

James Augustine, MD, FACEP, director of clinical operations at Emergency Medicine Physicians, an emergency physician partnership group based in Canton, OH, says, "I thought they may actually be underestimating what's going on in the market. It depends on how they surveyed the participants." What Augustine means is that at present there are no nationally accepted definitions for diversion, rerouting, and so forth. "At this point those are all community definitions," he says.

However the figures are calculated, Burt also notes that because 8% of the hospitals nationwide are not allowed to go on diversion, ED crowding is not just a diversion issue. Besides, she asserts, "diversion is not a best practice."

More solutions-oriented

Burt says that in the future her surveys are going to expand to address potential solutions to the problems it identifies. For example, in the 2007 survey they have added questions for hospital and ED directors about some of the things that were in the IOM report, such as electronic whiteboards; zone nursing, in which a nurse sees patients in a very specific set of locations, all next to each other; and some technology issues such as radio frequency identification (RFID), she shares.

The formulation of questions is critical in such surveys, Burt says. In 2002, it appeared that about 32% of EDs had electronic medical records (EMRs), she says. "But in 2005, we asked about specific system features, and when we started looking at those answers, and at what experts say EMRs really have to have, that number comes down to 5%," Burt says.

EMRs are another area in which the emergency field doesn't have good definitions, Augustine says. "We may have some EMR pieces in place, yet the entire EMR has not been perfected yet and certainly not implemented yet in the ED." The most developed system is the one at the Veterans Affairs (VA) medical centers, he says. "They are very far ahead on this," Augustine notes. "Their EMR is as functional and friendly as system makers can design them now."

The EMR at the VA is an internal product, developed with the Massachusetts Institute of Technology in Boston. The name given the basic database that all VA medical centers throughout the nation access is VISTA (Veterans Health Information and Technology Architecture

[Guest paramedico987]

Funny, isn't it? Everyone from all facets of our society both recognize and criticize hospitals for the problem, but nobody ever does anything about it!

People piss and moan that they've "been waiting here all day and nobody's seen them" when sitting in ED waiting rooms, but fail to realize that, perhaps, if they've spent the whole day sitting there and haven't died of their "illness" that it may not be an emergency, and that they are furthermore THE CAUSE OF THE PROBLEM.

So, what are we to do? I hold not any degree in business management, but I would very much like to see someone fund a study on how to IMPROVE the problem rather than once again identify one that we all already know exists.

Just letting off some more steam....

~987

p.s. Not whining at you als, just the problem at large. I actually rather enjoy your posts, keep 'em coming.

Edited November 21, 2006 by paramedico987

[Oswegowind 17]

My wife is an emergency room nurse at St. John's Riverside Hospital in Yonkers. She comes home every week with the numbers of patients that are there and wait more than 4 hours rising. Lack of staffing is one issue, but should they be able to turn persons away that do not have true emergencies? I don't know how to solve the problem, but it is going to go away on it's own. More and more our emergency rooms are becoming doctor's offices and clinics, why then do we have these other sites? There needs to be more funding, especially in urban areas where these problems are out of hand. I have a runny nose, I go get some medicine, not to the emergency room by ambulance and then ask for cab fare to the drug store to pick up the tylenol the doctor, whose time I have wasted, told me will work!!! Research is not needed, just talk to the nurses and emts, they will tell you what the problem is!

[WAS967 97]

Part of the problem could be nipped in the bud if the triage nurses, when they encounter a patient that qualifies as non-emergent, were able to ask the patient if they might perhaps be better off seeing thier own PMD. But then the hospitals wouldn't make money off all the patients that come to the ER for "the minor stuff". Insurance companies should stress more to thier subscribers that they should go to thier doctor for things like coughs, colds, minor suture issues, etc. People immediatly think ER, maybe because they are unaware of the abilities of thier own doctors.

[ny10570 745]

Most of the people clogging ER's with simple problems are there because they do not have private health insurance or primary care physicians. Medicaid allways pays out for ambulance transports and ER visits. The public needs to be educated about their options.

[Guest alsfirefighter]

I agree NY. You also have to keep in mind that the patient bill of rights and COBRA that came into swing with Bill Clinton also can put individuals and facilities at certain litigation risks even with simple vocabulary usage if in the right circumstances causes a problem for the "patient."

[ny10570 745]

Thats absolutely correct. Sadly, short of some sweeping change in the legal system holding people responsible for at least some of their actions, we have to continue to spoon feed the public info and keep everything very simple. Thats why we can't treat and leave pt's and ER's will continue to be our nations primary care physician, etc etc. In stead of going on, I'm just going ot stare at the window while I try and forget about the pt I just took to the ER because his cast was irritating his thumb.

[Guest paramedico987]

Although I'm not a Clinton fan per se, I have to correct ALS... HIPAA is Clinton's, COBRA is from 1985.

COBRA just says that people have the right to an eval... it doesn't say anything about a FREE eval. The hospital WILL get its money.

In January I cut my hand at work [just before punching in so comp didn't pay it] at around midnight and had to get sutures at Joe's... They pestered me for that over the top fee [while I was trying to convince worker's comp to pay] until I turned blue in the face.

What WOULD be justified would be to turn away those who had an excessive outstanding debt with the hospital... which would require a change to COBRA.

So if John Q. Drunk hasn't been paying his ER bill... John Q. Drunk doesn't get to see the doc anymore

[ny10570 745]

What WOULD be justified would be to turn away those who had an excessive outstanding debt with the hospital... which would require a change to COBRA.

So if John Q. Drunk hasn't been paying his ER bill... John Q. Drunk doesn't get to see the doc anymore

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Sorry bro, hospitals cannot and will never (I hope) be able to turn anyone away based on their financial status. Education combined with making them wait is the only solution I see. We have the wait, now we just need the education.