Of all the challenges that U.S. emergency departments face, probably the greatest is dealing with more patients than we can treat effectively. What a problem to have! Most businesses would give their eye teeth to have lots of customers, but for some inexplicable reason, we complain. We often act as if we are doing the patients a favor and that everyone is getting free care. This is far from the truth. In the vast majority of EDs in this country (but certainly not all), the payor mix generates a substantial income for the hospital and doctors. Most EDs with capacity issues are plagued by a problem that we seem incapable of solving: holding admitted patients in the ED.
Although reasonable solutions to this problem have been suggested (e.g., putting admitted patients on the halls of the wards), most administrators have chosen not to contaminate the rest of the hospital with these excess patients but rather hold them in the ED where they make the department malfunction substantially. Their reasoning: It may offend the medical staff, patients' families, and hospital floor staff. The philosophy is to sacrifice the ED and its patients for the sake of the rest of the hospital. Until recently, the perceived consequence of this decision was to reinforce the general beliefs of the community that EDs are associated with long waits and a litany of other indignities.
ED staff become frustrated and exasperated because it seems they are powerless to change the situation. The concept that excess patients are, in reality, a hospital challenge rather than simply an ED challenge has been a tough sell when you look at the typically impotent actions taken to address the problem. No, it is not an easy fix, but we could do a lot better. We need aggressive medical staff leadership driving lengths of stay; we need administrators willing to close the hospital to elective surgery when the ED has no place to put its patients; we need options to efficiently discharge admitted patients; we need hospitalists committed to providing efficient, evidence-based care; we need ICUs open only to those qualified to admit patients to these units (rather than every Tom, Dick, and Mary on the medical staff). And, yes, some of these initiatives will upset the medical staff, but hospital and medical staff leadership need to jointly step up to the plate and take on the challenge.
And why aren't regulatory agencies interested in the problem? It is obviously dangerous to be working in an environment that is substantially over capacity. It is obviously a problem when ED patients wait hours to see a doctor. It is obviously a problem when the rate of patients leaving the ED without being seen is five percent to 10 percent. With the mantra of patient safety on everyone's lips, how can these obvious problems be overlooked? It would be one thing if there were truly nothing that could be done, but this is fundamentally untrue. There are myriad solutions that have been demonstrated to facilitate turnaround times in the ED. It requires the hospital leadership (both medical staff and administration) to have the stomach to make some hard and not-so-hard choices.
Why not offer incentives? If the CEO's annual bonus were linked to ED patient throughput, it is guaranteed that most hospitals would see their problem solved. This may sound like an inflammatory statement, but truly, the only one who can fix the “ED problem” is the CEO. It is a top-down initiative. Driven by money or fear, it can be fixed. Money has already been suggested; make it a criterion for the bonus, and watch what happens. But what about fear? For all practical purposes, the most feared entity in the hospital world is the Joint Commission, and its ability to shut down a hospital gives it unprecedented clout. So why hasn't the Joint Commission taken on the hospitals, given its passion for patient safety and multiple initiatives in this matter? The crowded ED is a blatant patient safety issue, much more so than medication reviews by pharmacists, medication reconciliation, “time-outs,” or two patient IDs.
And now we have, after all of these years, data to support what all of us in the pit have known all along. It is not good medicine to be crowded. It is dangerous to be crowded. This is truly a no-brainer. The best study on this topic was published last June. Frankly, it is disappointing that it took this long to start getting the solid data needed to make the compelling point that these problems must be fixed; it is not just a matter of making people wait. It is, rather, a matter of life and death. This study provides the kind of ammunition that will help emergency physicians and anyone else interested in fixing our broken EDs drive the change that is so desperately needed.
The study showed that based on the outcomes of an assessment of 50,322 ICU patients treated in 120 ICUs in this country, the mortality of ICU patients boarded in the ED for six or more hours was 17.4 percent vs. 12.9 percent for those boarded less than six hours (a 35% relative increase). In addition, the hospital length of stay was longer by one day, and ICU mortality was also higher (10.7% vs. 8.4%) for the former group of patients. ED boarding for six hours or longer was an independent predictor of decreased survival. The number needed to harm: 20. For every 20 ICU patients boarded in the ED for more than six or more hours, one will die (the ultimate harm).
Impact of Delayed Transfer of Critically Ill Patients from the Emergency Department to the Intensive Care Unit
Chalfin DB, et al
Crit Care Med
BACKGROUND: Boarding critically ill patients in the ED (i.e., holding a patient in the ED pending ICU bed availability) is increasing in frequency, and might delay the provision of essential elements of care. The effect of this practice on outcomes is uncertain.
METHODS: These authors from various centers examined the effect of delayed transfer from the ED to the ICU on selected outcomes in 50,322 critically ill patients treated from 2000 through 2003 at one of 120 adult ICUs included in the Project IMPACT database developed by the Society of Critical Care Medicine.
RESULTS: Delayed transfer to the ICU (six or more hours after the decision to admit) was documented for 2.1 percent of the patients. There were no significant differences between these patients and those without delayed transfer in measures of illness severity. The median hospital length of stay in surviving patients was seven days in patients with delayed transfer to the ICU vs. six days in those without a delay in transfer (p<0.001). ICU mortality was 10.7 percent in the group with delayed transfer vs. 8.4 percent in the comparison group (p<0.01), and corresponding inpatient mortality rates were 17.4 percent vs. 12.9 percent (p<0.001). On logistic regression analysis, delayed transfer to the ICU from the ED was an independent risk factor for lower inpatient survival (odds ratio, 0.71). Other independent predictors included advanced age, higher APACHE II scores, male gender, and selected diagnoses (trauma, intracerebral hemorrhage, and neurologic disease).
CONCLUSIONS: This large study documents an adverse effect of boarding critically ill patients in the ED for six or more hours prior to transfer to the ICU.