Study: Not enough hospitals addressing ER overcrowding
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* Kim Krisberg

Even though emergency department overcrowding is associated with worse patient care and mortality rates, many of the nation’s hospitals have yet to implement proven interventions, researchers report.

In a study published in the December issue of *Health Affairs,* researchers found that overcrowded emergency departments adopted a greater number of interventions than less-crowded emergency departments. However, even among the most crowded emergency departments, a large number had not adopted proven intervention strategies, such as bedside registration and surgical schedule smoothing, which plans surgeries according to inpatient bed availability. On the upside, the average number of emergency department overcrowding interventions used by hospitals increased 25 percent between 2007 and 2010, from 5.2 to 6.6.

According to the study, emergency department crowding is a continuing problem in the U.S. and is associated with higher mortality rates, higher rates of cardiovascular complications among patients with chest pains and poorer patient experiences. Solutions that can be used to address overcrowding include interventions at both the hospital and emergency department levels, from implementing tracking systems to diverting ambulances.

“The first thing to realize when it comes to emergency room crowding is it’s a complex and multifactorial problem that involves many different stakeholders and many simultaneously interacting factors, so it’s not a simple problem,” said study co-author Jesse Pines, MD, MBA, director of the Office for Clinical Practice Innovation and a professor of emergency medicine and health policy at George Washington University School of Medicine and Health Sciences. “But from someone who works in an emergency department, I think this is a huge problem.”

To conduct the study, Pines and his research colleagues examined 2007-2010 data from the National Hospital Ambulatory Medical Care Survey, classifying each of the 17 overcrowding interventions studied as either a hospital-level intervention or an emergency department-level intervention. The final study sample included about 340 hospitals per year and a total of about 139,500 patient encounters, which represented a nationwide average of 127 million emergency department visits every year. Researchers found a significant increase in the average number of hospital-level interventions, from 2.2 in 2007 to three in 2010, but a nonsignficant increase in emergency department-level interventions, from three to 3.5.

The intervention that gained the most steam during the study period was full-capacity protocol, which moves admitted patients from the emergency department to inpatient units. Use of that intervention grew from 21 percent of hospitals in 2007 to more than 45 percent in 2010. Many more hospitals — an increase from about 10 percent to more than 20 percent — also instituted radio-frequency identification tracking, which allows a patient’s location to be tracked throughout the emergency department.

Researchers observed smaller increases among interventions that were already common in 2007, such as bedside registration and bed census availability. The one intervention that declined during the study period — from nearly 36 percent of hospitals studied to about 21 percent — was the presence of an emergency department observation unit, which extends observation times for patients who do not require admission in an effort to reduce short hospital stays. Still, a large proportion of the most crowded hospitals did not adopt proven interventions. For instance, 19 percent of the most crowded emergency departments had not adopted bedside registration and 94 percent had not adopted surgical schedule smoothing, the study found. Overall, researchers found that teaching hospitals were most likely to adopt crowding interventions.

“Hospitals have been slow to adopt interventions that require a change in hospital-wide protocols,” the study stated. “This may reflect the fact that (emergency department) crowding is a low hospital-wide priority in many facilities, despite the fact that it continues to worsen.”

Pines told *The Nation’s Health* that while crowding is now a national quality measure in health care delivery and included in accreditation standards that address patient flow, “there aren’t really teeth in either of those recommendations.” He predicted that at least in the short term, emergency department crowding will continue as more people become insured and seek out health services. However, he noted that the growth of retail clinics, urgent care clinics and freestanding emergency rooms could impact hospital crowding in the long term, as could changes in federal reimbursement rates that consider crowding measures as part of value-based purchasing.

“Unless it becomes a hair-on-fire issue for hospitals, we’ll continue to see slow adoption of interventions,” Pines said. “But the literature is clear that it’s more dangerous for patients to come in during crowded times. So from a public health perspective, reducing crowding needs to be a major priority.”

For more information, visit [http://content.healthaffairs.org/content/34/12/2151.abstract](http://content.healthaffairs.org/content/34/12/2151.abstract).

*   Copyright The Nation’s Health, American Public Health Association