About ED Crowding

"Hospitals can take steps today to improve patient flow. By using proven, low-cost strategies, they can achieve breakthroughs in quality and safety while creating a better workplace. Urgent Matters is a catalyst for developing and delivering strategies to support America's hospitals."

A Nationwide Concern
On June 14, 2006, the Institute of Medicine released a series of reports providing evidence that the Nation's emergency medical system is overburdened, underfunded and highly fragmented. As a result, patients must wait hours or even days for a hospital bed in many areas. One of three reports, "Hospital-Based Emergency Care: At the Breaking Point," investigates the epidemic of overcrowded emergency departments and trauma centers across the nation and the effects on the entire healthcare system. Read more >>

In August 2006, Urgent Matters interviewed Dr. John Lumpkin, Senior Vice President and Director of the Health Care Group for the Robert Wood Johnson Foundation, regarding the IOM reports. Dr. Lumpkin highlighted the phenomenal transformation in the emergency care system in the past 25 years because of training, education and available technology. In recent years, however, numerous conditions have brought emergency care to a crisis. Patient visits have increased dramatically while the number of hospital beds has decreased. The number of uninsured is rising and the emergency department faces new demands for better emergency preparedness. All of these factors are converging to create the "perfect storm" in emergency care. Read more >>

Emergency Department (ED) Crowding and Patient Flow
ED utilization in the U.S. increased by 18 percent from 1992 to 2004, while the number of hospital EDs decreased by 12 percent. (1) Many cities are now reporting dramatic increases in ED wait times and ambulance diversions, with implications for the health and health care of millions. In an April 2002 national survey, 62 percent of all U.S. hospitals reported being "at" or "over" operating capacity, with this proportion rising to 79 percent for urban hospitals, and 87 percent for level I trauma centers. (2)

Rising numbers of uninsured, an aging population, changing financial incentives and variations in medical practice all contribute to the ED crowding phenomenon. Patients entering the ED may also be sicker than they were in the past; one recent study found a 59 percent increase in the number of critical visits per ED in California from 1990 to 1999. (3) Other factors play a role in ED crowding including difficulties in recruiting and retaining qualified professional staff, shortages of willing on-call medical specialists, and the overall shrinkage of inpatient hospital capacity. Crowding reflects inefficiencies in community-based health care, the emergency department and the hospital.

Urgent Matters, a national program of the Robert Wood Johnson Foundation, is working to address the issue of ED crowding through its educational and research activities.

A Model for Examining EDs
The "input/throughput/output" model (see figure below) provides a structure for examining the factors that affect ED access, quality and outcomes.

• Input factors include why people present to an ED, such as an aging population, availability of alternative sites of care, insurance status and perceptions of quality.
• Throughput focuses on the actual operations of the ED, e.g., the design of ED processes, timely availability of medical specialists and ancillary services, and accessible clinical information.
• Output factors include the ability to transfer or discharge ED patients, e.g., move patients into critical care or other inpatient units, or to transfer patients to follow-up care in the community.

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(1) "Emergency Department Overload: A Growing Crisis", report prepared by the Lewin Group for the American Hospital Association, April 2002.

(2) McCraig LF, Nawar EN. National Hospital Ambulatory Medical Care Survey, Emergency Department Visit Data, Centers for Disease Control and Prevention, 2001.

(3) Lambe S et al., "Trends in the Use and Capacity of California's Emergency Departments, 1990-1999", Annals of Emergency Medicine, 39:4, April 2002, pp.389-396.