60 / 180
216
The ED has been forced to adapt to overcrowding by moving
the ED out to triage, with placement of health care providers
at triage, evaluation of patients in the waiting room or
hallways. For example, Scheuermeyer, et al., describes a
program for evaluation of possible acute coronary syndrome
patients in the ED waiting room rather than in a monitored
bed, and interestingly concludes that it is a “feasible alter-
native” (25). Art Kellermann, a notable US emergency physi-
cian and leader, wrote an accompanying editorial whose
title summarizes its content titled “Waiting room medicine:
has it really come to this?”(26).
E. Overcrowding increases mortality
The emergency medicine community has long been aware
of the dangers of overcrowding and delays in care, but has
an understandable reluctance to publish bad outcomes.
Several recent articles looking at large databases that
compare mortality rates in patients presenting during
times of overcrowding versus times of no overcrowding
conclude that the rate of death is higher during times of
overcrowding. Chalfin, et al., looked at the outcomes of ICU
patients subjected to a delay of greater than 6 hours to
transfer to an ICU and found an increased hospital length of
stay (LOS) (7 vs. 6 days) and higher mortality rates (10.7% vs.
8.4%) for these patients (27).
Singer, et al., also found an increasing mortality rate and
increased LOS as a function of how long the patient was
boarded in the ED (28).The mortality rate was 2.5% for
those boarded for less than 2 hours and increased to 4.5%
for those boarding for greater than 12 hours. Similarly, LOS
increased from 5.6 days to 8.7 days. In a study performed
in Western Australia, mortality was also shown to be higher
during times of ED overcrowding and the authors estimated
that effect to result in approximately 13 excess deaths per
year in their patient population (29).
F. Overcrowding causes ambulance diversion
According to the CDC, approximately 50% of EDs experi-
ence overcrowding, and a third of US hospitals have expe-
rienced ambulance diversion (30). Ninety percent of ED
directors report overcrowding as a recurrent problem, and
other studies have reported diversion in up to 50% of emer-
gency departments (31). Such overcrowding and diversion
have raised an alarm regarding the ability of the health care
system to respond to catastrophe.
Interestingly, there is scant evidence that ambulance diver-
sion actually works, although there is evidence for delayed
care in the face of ambulance diversion (32,33). In this
regard, Nicholl, et al., demonstrated an increased mortality
rate with prolonged transport times (34). What should be
clear is that ambulance diversion is driven by the boarding
of admitted patients, and not otherwise related to issues of
staffing or space within the ED itself (35).
WHAT ARE THE FINANCIAL CONSEQUENCES OF
BOARDING ADMITTED PATIENTS?
First, some numbers. In the United States, it is estimated
that it costs approximately $1,000,000 to build a hospital
bed, and $600,000 to $800,000 to staff that same bed.
Many have argued that this is the reason hospitals have
little interest in addressing the boarding problem. They are
more than happy to have patients lining up to get into the
hospital.
To increase or decrease the number of admissions from
the ED by one a day will net (positive or negative) around
$800,000 to the institution at the end of the year. Each
walkout from the ED represents roughly $600 to $800 in lost
revenue, ignoring the loss of a potential admission among
the walkouts. In separate studies, Falvo and Bayley evalu-
ated the potential financial consequences from boarding
patients in the ED (36,37).
Finally, it should be noted that decreasing overall LOS by
any means is of major financial benefit to the institution.
Shorter LOS for a given number of beds means that there
will be more capacity. A 600 bed hospital operating at
capacity with an average LOS of 6 days would need 500
beds for the same volume if the LOS decreased by a day.
HOW CAN BOARDING OF ADMITTED PATIENTS IN THE
ED BE REDUCED?
A. Solutions within the ED Internal to the ED
Internal to the ED, performing patient registration at the
bedside rather than in the front of the ED has been shown
to decrease waiting time for patients, but, at least in some
places, this effectis not sustained (38).The reasons for this
are unclear, but may be related to the failure to imple-
ment this in a consistent way, regardless of volume and
boarding.
One option to improve the care of patients waiting to be
seen is to address boarding by adding beds to the ED. The
study by Khare, et al., is one of several that conclude that
this is a less than ideal solution, and that the ED patient
is best served by moving admitted patients out of the ED
(39). This study is congruent with a number of other studies
which have demonstrated that increasing the number of ED
beds simply increased the number of boarders. Others have
similar conclusions (40).
[REV. MED. CLIN. CONDES - 2017; 28(2) 213-219]