Advertisement

Solutions for ED Overcrowding: Increasing Urgent Care Centers

      Dear Editor:
      Imagine the following scenario: It is 4 o'clock on a Monday afternoon. There are no seats; people are standing as patients line the walls in wheelchairs. A daughter is trying to get the attention of the triage nurse about why her mother has not been seen yet. The triage nurse is managing the triage of a patient and attending to a screaming woman in labor. People are complaining and comparing their wait times, ranging from 4 to 5 hours. There are no open rooms, and the number of patients waiting to be seen continues to increase. Unfortunately, this has become the typical day in the emergency department waiting room. Overcrowding is a pandemic across the United States that needs immediate intervention. As an emergency nurse, I face this crisis every day alongside my patients. I continually wonder about a solution. Increasing the number and utilization of urgent care centers will decrease overcrowding by deferring patients from the emergency department.
      Overcrowding is multifaceted and can be defined in terms of the emergency department's input, throughput, and output. A major contributor to the increase in input volume is the lack of primary care use and access for patients. Patients need an alternative to using the emergency department for their primary care needs.
      • Graham J
      • Aitken ME
      • Shirm S
      Correlation of measures of patient acuity with measures of crowding in a pediatric emergency department.
      • Cunningham PJ
      What accounts for differences in the use of hospital emergency departments across U.S. communities?.
      • Institute of Medicine
      IOM report: the future of emergency care in the united states health system.
      • Howard MS
      • Davis B
      • Anderson C
      • Cherry D
      • Koller P
      • Shelton D
      Patients' perspective on choosing the emergency department for nonurgent medical care: a qualitative study exploring one reason for overcrowding.
      In the last decade the number of emergency departments has decreased, yet the number of patients seeking emergency care has increased. More than 50% of ED patients report long wait times and 70% of emergency departments report needing to perform ambulance diversion because of overcrowding.
      • Institute of Medicine
      IOM report: the future of emergency care in the united states health system.
      • Kennedy J
      • Rhodes K
      • Walls CA
      • Asplin BR
      Access to emergency care: restricted by long waiting times and cost and coverage concerns.
      The rates of patients who leave without being seen are continually increasing. Overcrowding places extreme strain on providers as they become overwhelmed by the volume of care provided. During times of overcrowding, nurses have been forced to be task oriented and are unable to provide high-quality, patient-centered care. A contributor to overcrowding is the number of patients with nonurgent complaints who present to the emergency department. The rates of ED visits for nonurgent complaints vary from 20% to 50%.
      • Koziol-McLain J
      • Price DW
      • Weiss B
      • Quinn AA
      • Honigman B
      Seeking care for nonurgent medical conditions in the emergency department: through the eyes of the patient.
      • Milbrett P
      • Halms M
      Characteristics and predictors of frequent utilization of emergency services.
      These patients comprise both insured and uninsured, but the common link is a barrier to primary care access. The number of primary care clinicians is decreasing, especially in relation to the demand for care, and patients are waiting several days to weeks for an appointment. Primary care offices are typically only open on weekdays and normal business hours, whereas emergency departments are always open and can never defer or refuse to provide patient care. Therefore patients believe that they have nowhere else to turn but the emergency department when unable to see their primary care clinician.
      • Howard MS
      • Davis B
      • Anderson C
      • Cherry D
      • Koller P
      • Shelton D
      Patients' perspective on choosing the emergency department for nonurgent medical care: a qualitative study exploring one reason for overcrowding.
      Solutions must be identified to address patients' inability to access primary care services.
      Urgent care centers have been increasing in popularity over the last several years, with a 50% increase in the last decade. Urgent care centers evaluate and treat a broader scope of illness than primary care offices and function similarly to emergency departments. They are open 7 days a week with extended hours beyond normal business hours and do not require appointments. The typical wait time to be seen at an urgent care center is less than 30 minutes, compared with hours at an emergency department. Urgent care centers are run by physicians, nurse practitioners, and nurses trained in primary or emergency care, and most can perform basic laboratory tests, obtain radiographs, provide care for fractures, and offer intravenous fluids.
      Urgent Care Association of America
      The case for urgent care.
      • Weinick RM
      • Burns RM
      • Mehrotra A
      Many emergency department visits could be managed at urgent care centers.
      • Weinick RM
      • Bristol SJ
      • DesRoches CM
      Urgent care centers in the U.S.: findings from a national survey.
      They do not manage acute emergencies and could never take the place of emergency departments, but they do offer the ability to absorb patients from the emergency department who have nonurgent complaints. Although urgent care centers are not open 24 hours a day, the philosophy is that patients with nonurgent complaints can wait until morning to be seen. Urgent care centers decrease costs for patients and the health care system as a whole with a cost per visit that is approximately one-quarter the cost of an ED visit. If all nonurgent patients were seen at urgent care centers, the United States could possibly save *$18 billion a year. It is evident that urgent care centers offer a cost-effective alternative to emergency departments for nonurgent complaints.
      Urgent Care Association of America
      The case for urgent care.
      • Mehrotra A
      • Hangsheng L
      • Adams J
      • et al.
      The costs and quality of care for three common illnesses at retail clinics as compared to other medical settings.
      Because urgent care centers prove to be a part of the solution to overcrowding, why are emergency departments still being bombarded with nonurgent patients? This is in part because of the number and availability of urgent care centers. There are approximately 9,000 urgent care centers in the United States, with only 20% of them in urban areas.
      Urgent Care Association of America
      The case for urgent care.
      Urban areas are most affected by overcrowding and therefore should be housing the majority of urgent care centers. There should be a joint effort between health care providers and state and federal officials to allocate funding for the development of more urgent care centers in urban settings. A second issue is the uneducated public. Many people do not know what an urgent care center is or what services it has to offer. If people cannot be seen at their primary care physician's practice, they either are referred to the emergency department by their primary clinician or believe that the emergency department is their only option for care. In addition to increasing the number of urgent care centers, funding must be allocated to educating the public and advertising the resources of urgent care centers. If urgent care centers are readily available to communities and people understand their role and advantages, patients will use this resource and defer the cost and long wait times in the emergency department.
      The crisis of ED overcrowding has a dismal future, with access to primary care expected to worsen over the next several years. By 2020, there is an expected shortage of 45,000 primary care physicians. To further compound this, by 2014, approximately 32 million people will be insured and required to have primary care clinicians. The emergency department is already working at maximum capacity and cannot absorb more patients who are unable to find other sources of care. Urgent care centers are a piece of the solution. Urgent care centers have the capability to manage patients who have non–life-threatening emergencies. They offer a more cost-effective use of care and have the potential to absorb 30% to 50% of ED patients. However, a serious effort needs to be made to provide more urgent care centers in urban areas and educate communities about their resources. If solutions are not taken seriously, the national crisis of ED overcrowding is going to result in catastrophic outcomes.

      References

        • Graham J
        • Aitken ME
        • Shirm S
        Correlation of measures of patient acuity with measures of crowding in a pediatric emergency department.
        Pediatr Emerg Care. 2011; 27: 706-709
        • Cunningham PJ
        What accounts for differences in the use of hospital emergency departments across U.S. communities?.
        Health Aff. 2006; 25: 324-336
        • Institute of Medicine
        IOM report: the future of emergency care in the united states health system.
        Acad Emerg Med. 2006; 13: 1081-1085
        • Howard MS
        • Davis B
        • Anderson C
        • Cherry D
        • Koller P
        • Shelton D
        Patients' perspective on choosing the emergency department for nonurgent medical care: a qualitative study exploring one reason for overcrowding.
        J Emerg Nurs. 2005; 31: 429-435
        • Kennedy J
        • Rhodes K
        • Walls CA
        • Asplin BR
        Access to emergency care: restricted by long waiting times and cost and coverage concerns.
        Ann Emerg Med. 2004; 43: 567-573
        • Koziol-McLain J
        • Price DW
        • Weiss B
        • Quinn AA
        • Honigman B
        Seeking care for nonurgent medical conditions in the emergency department: through the eyes of the patient.
        J Emerg Nurs. 2000; 26: 554-563
        • Milbrett P
        • Halms M
        Characteristics and predictors of frequent utilization of emergency services.
        J Emerg Nurs. 2009; 35: 191-198
        • Urgent Care Association of America
        The case for urgent care.
        (Accessed November, 2011)
        • Weinick RM
        • Burns RM
        • Mehrotra A
        Many emergency department visits could be managed at urgent care centers.
        Health Aff. 2010; 29: 1630-1636
        • Weinick RM
        • Bristol SJ
        • DesRoches CM
        Urgent care centers in the U.S.: findings from a national survey.
        BMC Health Serv Res. 2009; 9: 1-8
        • Mehrotra A
        • Hangsheng L
        • Adams J
        • et al.
        The costs and quality of care for three common illnesses at retail clinics as compared to other medical settings.
        Ann Intern Med. 2009; 151: 321-328