62 / 180
218
CONCLUSION
ED overcrowding is caused by institutional overcrowding,
with resultant boarding of admitted patients in the ED.
There is no evidence that overcrowding results from excess
poor patients or non-urgent visits. ED overcrowding causes
multiple problems for ED patients and staff, including
increased waiting times, increased ambulance diversion,
increased length of stay, increased medical errors, increased
patient mortality, and increased harm to hospitals due to
financial losses.
ED overcrowding can be addressed by a variety of mecha-
nisms. Internal department improvements include bedside
registration and effective use of hospitalists. Providers
in triage and provider schedule optimization are addi-
tional solutions. Adding beds to the ED does not predict-
ably improve problems with boarding and overcrowding.
Externally, the smoothing of elective (schedulable) admis-
sions probably is the single most important intervention
to improve capacity, decrease boarding, preserve nurse/
patient ratios, and improve ICU access. Were there to be
a system-wide implementation of smoothing, it is likely
that there would be no capacity issue. Early morning
discharges from inpatient units also substantially decreases
ED boarding.
Increasing weekend discharges and improving services
available on weekends will result in improved capacity
and decreased boarding. When the number of admissions
exceeds the number of beds at an institution, having a
full-capacity protocol, where the inpatient units go over
census rather than boarding patients in the ED, is safer, is
preferred by patients and shortens length of stay. Ambu-
lance diversion has not been shown to be effective, and has
multiple adverse effects on both patient care and the finan-
cial health of the institution. Until healthcare and hospital
administrators recognize that ED overcrowding really is
hospital overcrowding, this issue will likely to continue to
garner attention without meaningful progress being made
to address the underlying issues.
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