A study to be published in the August 2003 Annals of Emergency Medicine adds further evidence that boarding inpatients and a shortage of on-call physicians are major contributors to emergency department crowding and ambulance diversion.
Lack of Treatment Space
A point-in-time survey of nearly 90 hospital emergency departments
across the country on a typical Monday evening (March 7, 2001 - 7 p.m. local
time) found 100 percent of treatment spaces to be occupied. Fifty-nine percent
(51/86) of emergency departments reported routine use of hallways for treatment,
38 percent (32/84) reported placing more than one patient per available bed, and
47 percent (40/85) reported using non-clinical spaces for patient care.
According to the study authors, non-clinical spaces include offices, storerooms,
conference rooms and even showers where patients are placed when the emergency
department is overcrowded. These areas were not designed as treatment rooms and
usually do not have equipment in them. Seventy-one percent (62/87) of emergency
departments reported routine use of at least one of these options when
overcrowded.
Boarding Patients
Seventy-three percent of the emergency departments reported boarding
two or more inpatients, which confirms the practice of boarding inpatients is
widespread and significantly contributes to overcrowded conditions. Inpatients
are those individuals who have been admitted to the hospital, but must wait in
the emergency department until a bed in the hospital opens up. This practice in
the emergency department is known as "boarding."
To ensure these results were not atypical, researchers asked about the previous seven days, and nearly half (48 percent) of emergency departments reported boarding inpatients for a mean of 8.9 hours per day, 4.2 days per week. If inpatients were not housed in the emergency departments studied, the number of crowded departments would decrease by 30 percent, according to the study authors.
This study found only 11 percent of emergency departments went on ambulance diversion, despite that 59 percent were routinely using hallways to care for patients, and 49 percent lacked the appropriate number of nurses.
On-Call Physician Shortage
Another contributing factor to emergency department crowding is the
shortage of on-call specialists, according to the study's authors. Researchers
found patients waiting in emergency departments for consultations by on-call
physicians accounted for 7.6 percent of patients in the emergency department;
however, 36 percent of emergency departments had two or more patients waiting
for consultants.
Staffing Shortage
Personnel resources were found to be limited in emergency departments,
according to the study's authors. In 49 percent (39/79) of emergency
departments, each nurse was caring for more than four patients (a mean of 4.2
patients per nurse). According to standards set by the Society of Academic
Emergency Medicine (SAEM), emergency departments ideally should have separate
charge and triage nurses, and a patient/nurse ratio of 1-to-1 for critical care
beds, and a 4-to-1 ratio for routine beds. The study authors said they chose a
minimum-staffing ratio of four patients to one nurse (ignoring any critical care
beds) with one additional nurse for triage (significantly less than SAEM
suggests) as their benchmark for the emergency departments surveyed.