Emergency Department Crowding: A Call to Action in the New Year

There is a disease brewing in our country, but not the kind that is cured by antibiotics or the surgeon’s knife. You know it as Emergency Department (ED) crowding. Its symptoms are well known: too many patients, too little space, long wait times, and the resulting anger and frustration. Research reveals severe consequences of crowding: delay in diagnosis, increased walk-outs of patients needing care, increased medical errors, ambulance diversions, increased hospital length of stay, increased negligence claims, and increased mortality.

This new disease’s pathology has little to do with the ED itself. Building a bigger one is not the solution; rather, the solution can be found in opening the flow of patients out of the department to inpatient beds and community services. Increasing the efficiency of the ED will help, but increasing the efficiency of the hospital will have a broader, longer-range effect. High-impact solutions include scheduling surgeries and elective admissions to even the patient census, changing to a hospital-wide 24/7 operational culture rather than a Monday through Friday one, using alternative sites for admitted patients (e.g., observation units or admissions units), and increasing inpatient admission and discharge efficiency. Importantly, ED nurses must be at the table whenever key decisions are being made involving a hospital’s patient flow.

Like other diseases, we must drill down to the cellular level. ED crowding is a sign of a weak health care system. The ED provides the safety net for the health care system and, hence, reveals the system’s flaws. Hospitals relentlessly have been forced to contain costs, most notably by the Balanced Budget Act of 1997, which reduced Medicare payments by $116 billion. Some bedding decisions are affected by a reimbursement system that favors surgical or cardiac catheterization lab patients over medical patients. Access to primary care is a major issue for the uninsured or under-insured. Unlike any other “business,” the Emergency Medical Treatment and Active Labor Act mandates that the ED accept everyone in need.

In February, ENA will host a meeting in Washington, DC, with major stakeholders on the topic of ED crowding with the hopes of forming a coalition of nursing and medical groups to address the problem.

There are three things I would like every emergency nurse to do to begin to address crowding:

Now is the time for change, with a New Year, new president, new cabinet, and a new Congress. Who better to be driving that change than emergency nurses?