Large EDs Bear Brunt of Crowding

John Commins, for HealthLeaders Media , May 27, 2009

Large, metropolitan emergency departments that serve more than 50,000 patients each year represent just 17.7% of all emergency departments in the nation, but they accounted for 44% of all ED visits in 2007, a new Centers for Disease Control and Prevention survey shows.

The new report, Estimates of Emergency Department Capacity: United States 2007, suggests that small EDs with annual visit volume less than 20,000 patients may not be experiencing the same levels of crowding.

The survey, conducted by the CDC's Division of Health Care Statistics, notes that over the last several decades the role of the ED has expanded from treating seriously ill and injured patients to providing urgent and unscheduled care for Medicaid and uninsured patients unable to access primary care.

The inability to transfer ED patients to an inpatient bed once they're admitted is a big factor in crowding. "As the ED begins to 'board' patients, the space, the staff, and the resources available to treat new patients are further reduced," the survey states. "A consequence of overcrowded EDs is ambulance diversion, in which EDs close their doors to incoming ambulances. The resulting treatment delay can be catastrophic for the patient."

The survey says that approximately 500,000 ambulances are diverted annually in the United States–an average of one diversion per minute.

The CDC survey, which is part of the National Hospital Ambulatory Medical Care Survey, also found that one-half of all hospitals with EDs had a "bed czar," 58% had elective surgeries scheduled five days a week, and 66% had bed census data available instantaneously.

Electronic medical records–either all electronic or part paper and part electronic–were reportedly used in 61.6% of EDs. Basic EMR systems containing patient demographics, problem lists, clinical notes, orders for prescription, and viewing laboratory and imaging results were reported in 15% of EDs.

However, the CDC report could not accurately determine ED use of fully functional EMRs–which includes prescription orders sent electronically, warnings of drug interactions, orders for tests, out-of-range test levels highlighted, medical history and follow-up, and reminders for guideline-based interventions.

The survey also found that:

  • EDs with more than 20,000 annual visits comprised more than 70% of EDs in metropolitan statistical areas. When compared to EDs in rural areas, EDs in MSAs were twice as likely to have a bed coordinator or bed czar in their hospital–60.7% compared with 30%; and board patients for more than two hours in the ED while waiting for an inpatient bed–77% to 32.8%.

  • More than one-third of EDs had an observation or clinical decision unit. Admitted ED patients were boarded for more than two hours in the ED while waiting for an inpatient bed in 62.5% of EDs. Among EDs that boarded patients, nearly 15% used inpatient hallways or another space outside the ED when it was critically overloaded.

  • In the previous two years, 24% of EDs increased the number of standard treatment spaces. Although more than 19% of EDs expanded their physical space in the last two years, 31% of those that did not expand their physical space plan to do so within the next two years.

  • The frequency of ED patient care techniques was as follows: bedside registration–66%; computer-assisted triage–40%; zone nursing–35.3%; electronic dashboard–35.2%; separate fast track unit for non-urgent care–33.8%; pool nurses–33.2%; full capacity protocol–21%; and radio frequency ID tracking–10%.

  • When compared with small EDs, large EDs were more likely to have a bed coordinator in their hospitals–71.2% compared with 33.8%; have an observation or clinical decision unit–53.5% to 32.5%; board patients for more than two hours in the ED while waiting for an inpatient bed–86.5% to 39%; and use bedside registration–89% to 54.2%; computer-assisted triage–62.2% to 24.3%; and zone nursing–62% to 19%.

John Commins is a senior editor with HealthLeaders Media.

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