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Legal Notes

Crowding Irrefutably Puts Patients and EPs at Risk

Glauser, Jonathan MD, MBA

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doi: 10.1097/01.EEM.0000359173.06994.30

    So much has been written about emergency department crowding in recent years that I would be remiss not to mention this as a legal risk to emergency physicians and a medical risk to patients. ED crowding as a major health problem and public issue has been in our literature for years (Ann Emerg Med 2002; 39[4]:430), and can safely be claimed to be irrefutable.

    A striking fact worth noting is that the patients who wait more than 30 minutes to see a physician are five times more likely to sue than those who are seen within 30 minutes. (“Emergency Department Crowding: High-Impact Solutions.” ACEP Task Force on Boarding. April 2008; This is especially disturbing because, failing a completely dysfunctional triage system, those patients not seen in 30 minutes should theoretically be less sick than the ones seen immediately. The implication that an irate patient with an ankle sprain is more likely a litigant than a patient with a STEMI seen promptly should grab our attention.

    We should be alarmed at a recent survey finding that 44 percent of emergency physicians polled said their EDs are understaffed, and 40 percent said understaffing negatively affected patient safety. (EPM 2009;16[5]:1.) Of course, our productivity is measured in patients seen per hour, RVUs generated per hour, or overall census. If ED crowding is all about held admissions, then the reported workload and nursing and physician staffing patterns of the ED should reflect the number of patients being cared for at any given time.

    Problem Isn't Going Away

    It may be that there is no or insufficient surge capacity in this country. It simply does not pay for hospitals to keep empty beds staffed waiting for emergencies and disasters. In our current reimbursement system, elective surgery and cardiac workups pay well. Even if they did not, emergency admissions are disruptive to planned processes, especially scheduled operating room procedures. The market is not going to create more inpatient availability for ED admissions; it is debatable whether government regulation to mandate a number of beds for unscheduled admissions is feasible, but short of outside intervention, this isn't going to happen.

    Other factors are not going away either. Data only a decade or two ago indicated that EPs might see 1.8 to 5.0 patients per hour in an undifferentiated emergency department. That figure was scaled down to 2.4 patients per hour in one widely cited publication more than 20 years ago. (Emergency Medicine Risk Management. Irving, TX: American College of Emergency Physicians; 1997; Physician Staffing in Management of Emergency Services. Rockville, MD: Aspen Publishers; 1987.) The population is aging, and has more complex disorders on presentation. If the ED of the future is one that sees a progressively older and sicker population, we will have to rethink how we approach care of the elderly. Many experts challenge anyone to undress an octogenarian referred from a long-term facility, obtain a reliable list of his medications, and secure a urine specimen in under 20 minutes.

    Who is Responsible?

    There are hardly any publications regarding ED crowding that do not cite boarded patients as the primary cause. Because a fair amount of literature has documented bad outcomes and prolonged hospital stays among boarded patients (Acad Emerg Med 2005;12[5 Suppl 1]:49; Med J Aust 2006;184[5]: 213), it's fair to ask which providers are responsible for admitted ED patients waiting for a bed. Emergency medicine's answer is unequivocal: Boarded patients are the responsibility of the admitting service. That, by the way, has to be the stance of any emergency physician, or the number of new patients we are expected to see per hour becomes a moot point.

    Experts advise EPs not to skip meals during a long shift and to limit the number of patients being actively managed to six. (Six!) At that number, sensory overload presumably kicks in, and we should be making some dispositions. With sick inpatients to manage, it becomes impossible to adhere to any given number of active new patients per hour.

    Is crowding a defense for bad outcomes? This is not a winnable argument, in court or with one's hospital administration or medical staff. Eight people may be sympathetic to a doctor who has to manage many patients in hallways while a hospital is booking lucrative elective surgeries, but it is perilous and unwise to be at odds with one's hospital, financially or in court.

    We should make it clear that the official care of admitted patients changes hands at the time of admission, but we also know that we have to take responsibility for adverse outcomes in the ED, for preventing those results, and for the comfort of any patient in our department.

    The Bottom Line

    Moving patients from ED hallways to inpatient hallways may work in some settings but not most. This is the most frequently cited solution to ED crowding, but patients are dissatisfied sitting in any hallway. Still, the most unsafe place for a patient is in the waiting room, unseen. Do whatever it takes to avoid this within the culture of your institution. I always work under the assumption that patient safety will ultimately reward us in the tort system.

    It is besides the point whether all those EPs who feel they are working in understaffed EDs really are in an unsafe environment. The perception should be enough to change the way we practice. I personally take people at their word when they feel overwhelmed. Some people are whiners, some are lazier than others, but a perception of understaffing is enough to worry me. We need to look hard at the processes and resources brought to this problem.

    I have never really had much use for tracking patient census as an excuse for an untoward event. I know attorneys will always look at staffing patterns and patient census when an EP discharged a patient with crescendo angina. Yet the activity of an ED cannot be tracked accurately by number of arrivals, especially if held admissions are not counted in the workload for physicians and nurses. No tracking system I have found will accurately reflect how time-consuming each patient was at the time. Numbers may not lie, but they can mislead.

    © 2009 Lippincott Williams & Wilkins, Inc.