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Breaking News: Intensity of Care, not Boarding, May Be Clogging EDs

SoRelle, Ruth MPH

doi: 10.1097/01.EEM.0000425840.34239.a1

    Crowding grows worse, boarders are still stacked in ED hallways, and call after call for solutions falls on seemingly deaf ears. But are the many solutions proposed for those common ED dilemmas really addressing the right problem?

    Maybe not, according to new research from Jesse Pines, MD, MBA, the director of the Center for Health Care Quality and an associate professor of emergency medicine and health policy at George Washington University in Washington, D.C. It may be that intensity of care — not boarding — is choking EDs.

    Emergency medicine policy experts note that ED visits increased by 1.9 percent per year from 2001 to 2008, a rate 60 percent faster than population growth. (Ann Emerg Med 2012 Jun 20; see FastLinks.) But occupancy climbed even more, increasing 3.1 percent per year during the same period, 27 percent overall for the eight-year study period.

    Use of advanced imaging techniques greatly lengthened ED stay, but had less influence on occupancy than common throughput factors such as administering intravenous fluids and performing procedures, Dr. Pines said. It was those dramatic surges in care intensity that extended length of stay in emergency departments.

    “It was a little surprising,” he said. “The expectation was that we would find that this would be driven by increases in radiography. Some of it was, but the bigger piece was an increase in lab test use and intravenous fluids.”

    The Institute of Medicine's landmark report seven years ago on the state of the emergency care system described a network in crisis where ambulances are turned away from EDs once every minute and patients wait hours or even days for a hospital bed. “The nation's emergency medical system as a whole is overburdened, underfunded, and highly fragmented,” according to the report's preamble.

    That strong language, intended as a wakeup call, had seemingly little effect, however, and the problem only grew in the interim. Dr. Pine's research, however, may prompt policymakers to address the issue from a different angle. The study reviewed data from the National Hospital Ambulatory Medical Care Survey using patient records from a national sample of hospital EDs to generate estimates of visits. The researchers used time of emergency department arrival and the length of the visit to calculate mean and hourly emergency department occupancy, linking it to the use of advanced imaging. Though that rose sharply — 140 percent — administering intravenous fluids, running blood tests, performing any clinical procedure, and a patient taking two or more medications were what really gummed up the works.

    Adding to the concern are the results of a study led by Steven L. Bernstein, MD, an associate professor and the vice chair of academic affairs for emergency medicine at Yale University School of Medicine. Dr. Bernstein and colleagues found in that review of 42 articles that ED crowding is associated with an increased risk of dying in the hospital and delayed treatment for disorders such as pneumonia or acute pain. It was not, however, associated with increased times to reperfusion for patients with ST-elevation myocardial infarction. (Acad Emerg Med 2009;16[1]:1; see FastLinks.)

    “We were hoping that issues of crowding would get better traction at the policy level,” said Dr. Bernstein. “The Government Accounting Office has paid attention in an April 2009 report, and the Joint Commission has put out some regulations about crowding, but nothing had a lot of teeth to it. Maybe that is the best we could have hoped for.” (See FastLinks for those reports.)

    Despite findings that patients are receiving a greater number and more sophisticated diagnostic tests and treatment in the emergency department, Dr. Pines warned that boarding should not be discounted as a major cause of crowding. “As the boarders stack up, the new undefined patients have less space in which to be seen, which causes long waits. It is still a major issue, and one that needs to be legislated because it's associated with worse outcomes.”

    Indeed, Dr. Pines and some of his colleagues think that might be the answer, as they noted in the journal Health Affairs. (2012;31[8]:1757; see FastLinks for abstract.) “Boarding is a major cause of emergency department crowding and is associated with inferior patient outcomes,” the authors concluded. “Boarding is a systemwide problem, and successful responses require the endorsement of hospital leaders. Proven strategies to reduce boarding are grossly underused. If continued education of hospital managers and the public does not result in change, enhanced regulation will be necessary to protect patients.”

    Dr. Bernstein said the medical staff in his hospital is moving toward accepting that crowding involves the entire hospital, not just the emergency department. “It reflects inefficiency in how resources are deployed. The emergency department mirrors that, but it is not the cause. It is a matter of local will to get something done,” he continued.

    Institutions do care about this issue, he said, though he acknowledged that likely not for the same reasons he does. “They want to keep their patient base happy and satisfied and coming back. I find in the places I've worked there is some increasing attention to efficiency and throughput and to reducing institutional barriers. Hospitals do have some strategies to fast-track admission upstairs. They have prehospital activation of the cath lab for ST-elevation myocardial infarctions. Institutions have done a number of things to mitigate crowding to some extent,” Dr. Bernstein said.

    Hospitals anticipating big cuts in reimbursement in the coming era of health reform are seeking more customers, and he said he would like to see mitigating crowding be part of that. “The basic message we are trying to convey is that this affects every domain of quality as defined by the IOM,” he said. “It's not just about time limits and not just about safety. It is about being patient-centered.”

    Dr. Pines pointed out that boarding, which is associated with worse outcomes, is something that hospitals can fix. “Doing that is a challenge sometimes because the hospital has to implement new processes or change their processes to get patients upstairs faster. It involves leadership and groups of people to get together and work together to identify problems and solve them,” he said. “That can be difficult to do in a hospital setting where so many people are involved in care of the patients.”

    The problem involves two different concepts, Dr. Pines said: how crowded it is when the patient gets to the emergency department, which is associated with higher rates of medical errors and complications and worse care, and boarding patients and the length of time they have to wait in the emergency department before they get upstairs. “Boarding in particular is associated with higher mortality rates in older adults and critically ill adults,” he said. “There are a lot of solutions out there, and the hospitals need to implement them. There has to be sufficient motivation to implement them. Some of the motivation may be public reporting of their data. It could potentially be pay-for-performance. Or it could be the implementation of penalties for not doing it.”

    Dr. Pines said no clear data document that patients are sicker these days, but the evidence shows that they are receiving more tests and treatments. U.S. emergency departments have become the rapid diagnostic centers for all of medicine and the staging ground for critically ill patients and those with acute complaints who need tests, he said. “Many times, patients are referred in for these tests by their PCPs [primary care physicians] who have a hard time arranging such tests on an outpatient basis.”

    EDs see many critically ill patients, Dr. Pines said, but added that he thought crowding also reflects changes in standard of care. “Historically, we physicians used to rely more on clinical judgment, but now people are relying more on objective imaging and objective lab tests to make clinical decisions for a lot of different reasons.”

    Hospitals have increasingly relied on patient satisfaction surveys, he said, and studies show that “tested patients are happier patients than untested patients. Doing more for people just takes longer.”

    Solutions for decreasing boarding are to speed the admission of patients to inpatient units of the hospital and to reduce the interventional nature of emergency care, a bold move that could be accomplished by implementing evidence-based clinical decision rules and asking doctors to follow them. Hospitals could also give careful consideration to incentives that encourage physicians to do as much as they can for patients on different levels to improve satisfaction scores.

    “We have to carefully consider how those incentives may increases costs or may or may not contribute to quality,” said Dr. Pines. “I don't think the trend toward an increased focus on patient satisfaction is going away soon, but it's certainly one major reason we are doing more, because patients want it.”

    Dr. Pines said he sees hope in the Patient Protection and Affordable Care Act that may change the way doctors and hospitals are paid to manage patients and coordinate care. It is unproven, but has promise, he said. “Two areas that need more focus include looking more closely about why physicians make the decisions they do and why patients make the decisions they do,” Dr. Pines said.

    Click and Connect!Access the links in EMN by reading this issue on our website or in our iPad app, both available


    • Read an abstract of “National Trends in Emergency Department Occupancy, 2001 to 2008: Effect of Inpatient Admissions Versus Emergency Department Practice Intensity,”at
    • An abstract of the study, “The Effect of Emergency Department Crowding on Clinically Oriented Outcomes,” is available at
    • Read the April 2009 GAO report on crowding at and the Joint Commission regulations on crowding at
    • An abstract of the Health Affairs study is online at
    • Comments about this article? Write to EMN at
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