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previously inpatient procedures shifted to the ambulatory
setting, left behind is a much sicker patient population,
filling the hospital to capacity. Rather than scheduled
admissions, the majority of patients enter through the
ED, with most of these entering the hospital in the after-
noon and evening. In most EDs, the volume of admissions
varies little from day to day or from weekday to weekend.
And yet, in far too many ways, hospitals have continued to
function 9am-5pm, Monday through Friday, with a skel-
eton crew on evenings, nights, and weekends. This may,
in part, explain the higher death rate for strokes and heart
attacks in patients admitted on weekends versus weekdays.
With current average LOSs of 5-6 days and median LOSs of
3 days, the model of once-daily rounding also makes far
less sense.
With this mismatch of resources versus need, there should
be little surprise that capacity issues would arise.
How does the institutional structure create capacity issues by
design? A classic example is in surgical scheduling, which is
not done smoothly throughout the week, but is rather front-
loaded near the beginning of the week. Why? An orthopedist,
for instance, knows that his or her patient undergoing hip repla-
cement is critically dependent upon physical therapy in the
days immediately following surgery, to prevent life-threatening
postoperative complications. If the hospital’s physical therapy
staff is small or nonexistent on weekends, then the orthopedist
has little choice but to schedule as much surgery as possible at
the beginning of the week. Thus, a “traffic jam” is created in which
the hospital is loaded up earlier in the week, so much so that
some institutions look like a 3-day-a-week business. This has a
domino effect on the entire institution. In fact, when an institu-
tion in Massachusetts, which had struggled with capacity issues
for years, changed to a smooth surgical schedule, their
capacity issues disappeared.
Capacity issues are further worsened by the failure to
discharge patients on the weekends, which would provide
more capacity as the week begins. In New York state,
weekend discharges are almost half of weekday discharged.
are almost half of weekday discharged. Surgical patients
discharged on a Monday vs Saturday had a length of stay of
10.22 days vs 6.56 days; for medical patients, this difference
was 5.12 days vs 3.90 days. This data clearly indicates a very
substantial opportunity for creating capacity to ameliorate
boarding. Montefiore Hospital in NYC reduced the average
number of boarders from 20 to near zero by a focused
and successful effort to increase weekend discharges. This
intervention was so successful that it reduced their overall
length of stay by a day, and allowed for closure of a 30 bed
unit (personal communication, AV).
Contrary to conventional wisdom that ED volume is highly
unpredictable, the number of admissions per day can be
predicted with remarkable accuracy. What is most striking
about this fact is the associated fact that no hospital actu-
ally anticipates and prepares for the next day’s volume of
admissions from the ED.
This paper will endeavor to answer some of the vital ques-
tions concerning ED overcrowding and propose some
possible solutions to this critical issue.
WHAT IS ED OVERCROWDING?
Various studies have developed definitions of ED over-
crowding, but in its simplest form, overcrowding exists when
there is no space left to meet the timely needs of the next
patient requiring emergency care. If the care of urgent prob-
lems is delayed due to congestion, then overcrowding exists.
The presumption for many years was that waits were driven by
poor ED design and failure to optimize flow. In some circum-
stances, this is unquestionably true. A substantial volume of
literature, however, concludes that ED overcrowding is largely
driven by the boarding of admitted patients in the ED. Thus ED
overcrowding is really a result of hospital- wide overcrowding.
One scoring system which has become a national standard
for measuring the degree of overcrowding is the National ED
Overcrowding Scale (“NEDOCS”)
(http://www.nedocs.org) (1).
Elements of the NEDOCS score include number of beds in the
hospital as well as the ED, total patients in the ED, number of
admits in the ED, number of patients on ventilators in the ED
as well as the waiting time of the longest admitted patient and
the longest waiting room patient.
WHAT CAUSES ED OVERCROWDING?
Over the years, the list of reasons for overcrowding have
included: the poor and uninsured who lack primary care;
unnecessary visits, the safety net, surgical scheduling and
seasonal illness.
Studies on the uninsured do not support the contention
that they use the ED more than insured patients, or that
they are a substantive cause of overcrowding (2).Further-
more, there is little evidence that low-acuity patients
impact waiting times or overcrowding in any event (3).More
recent studies have shown that “frequent flyers” represent
the sickest patients, have the greatest admission rates,
highest mortality rates, and consume a disproportionate
amount of resources (4).
In a study done in the state of Oregon looking at patients
who had public-based insurance (Medicaid), 23% of patients
[REV. MED. CLIN. CONDES - 2017; 28(2) 213-219]