The combination of hospital downsizing and greater emergency department (ED) use by sicker patients has led to overcrowded EDs that often have to divert ambulances to other hospitals. Several policy issues must be addressed to alleviate hospital and ED crowding over the long term, according to Robert W. Schafermeyer, M.D., F.A.C.E.P., of Carolinas Medical Center, and Brent R. Asplin, M.D., M.P.H., of the University of Minnesota School of Medicine, in a recent commentary. Dr. Asplin's work was supported by the Agency for Healthcare Research and Quality (K08 HS13007).
In response to reduced reimbursement from Medicare and Medicaid and other cost pressures, hospitals scrambled to reduce any excess supply of inpatient beds, and the number of hospitals with EDs shrunk from 6,000 to less than 4,000 over the period 1992 to 2000. Hospitals also struggled with the shortage of registered nurses (RNs), while the annual number of ED visits climbed from 90 to 108 million.
Although coastal areas have been more seriously affected than other areas, almost every State has reported problems with finding beds for patients admitted to the hospital from the ED. When an inpatient bed isn't available, or when the bed is available but there is no nurse to staff it, patients wait in the ED. This period of "boarding" in the ED can last from hours to days, and it is a major source of ED crowding.
An April 2002 American Hospital Association survey confirmed all of these trends. Overall, 62 percent of hospitals, 75 percent of urban hospitals, and 90 percent of Level I trauma centers believed they were at or over capacity. Also, one-third of hospitals had some period of time when they had to divert ambulances to other hospitals, primarily due to lack of available staffed critical care beds.
Reduced government and managed care payments, more uninsured patients, and the increased cost of malpractice insurance are all affecting access to emergency care. The authors suggest operational changes, for example, improved admission and discharge processes, and policy changes related to reimbursement and tort reform to alleviate capacity bottlenecks, reduce boarding in the ED, and eliminate ambulance diversion.
See "Hospital and emergency department crowding in the United States," by Drs. Schafermeyer and Asplin, in Emergency Medicine 15, pp. 22-27, 2003.