Emergency Room Crowding

 

Tuesday, March 14, 2006

Emergency Room Crowding

The email I wrote to Keith Steffen, adminstrator at OSF-SFMC, dated September 27, ‘01, described my thoughts and concerns about the OSF- ER after working an afternoon shift the day before. Elderly patientes signed out and went home because they just didn’t want to wait for a bed in the hospital to open up so they could be admitted. I felt very uneasy signing these sick people out of the ER to go home.

The Annals of Emergency Medicine headline an article in the January, 2000 issue “Overcrowding in the Nation’s Emergency Departments: Complex Causes and Disturbing Effects”. During the 90’s, overcrowding in emergency departments became a national issue. It didn’t just involve OSF in Peoria. The article stated, “ED overcrowding has multiple effects, including placing the patient at risk for poor outcome, prolonged pain and suffering of some patients, long patient waits, patient dissatsifaction, ambulance diversions in some cities, decreased physician productivity, increased frustration among medical staff, and violence….Unless the problem is solved in the near future, the general public may no longer be able to rely on ED’s for quality and timely emergency care, placing the people of this country at risk.”

In my opinion, this described OSF-ER almost perfectly. Thus, when I wrote Steffen my concerns and then met with him for the first time in early October, I had no idea that he would metaphorically refer to me in the meeting as a “cancer in the ER that needs to be cut out before it metastasizes” as well as a “hemorrhage that needs to be stopped before the bleeding gets out of control”. How his medical descriptions of me as a cancer and a hemorrhage related to bed capacity and overcrowding at OSF, remained a mystery to me. He didn’t seem to be focused on the important issues for OSF. He seemed to be focused on the concept of fear amongst employees and finding out from me which nurse started a petition in support of me and the problems I had addressed. And the ER director, George Hevesy, put me on probation for 6 months from working the ER the day after I sent this letter.

Almost a year after Steffen fired me from OSF, an article appeared in the journal “Academic Emergency Medicine”–The Elusive Nature of Quality. It discussed that systems need to change before emergency rooms can change for the better:

“Front line care providers (doctors working in the ER) are the frequent targets of criticism regarding the quality of care, and are often the recipients of the metrics we use to measure quality. These dedicated, skilled, and talented clinicians are often powerless when systems changes are needed, but they are held accountable for their actions within a SYSTEM THAT CANNOT ALLOW SUCCESS.

“The true route to achieving quality begins with an enduring commitment from the highest leaders of the organization, willing to exercise their authority for productive benefit. If the board of trustees and the CEO do not actively support excellence in the ED, enduring improvements are unlikely.

“If the messasge is not loud and clear that the patients in the ED must be served optimally by every service with impact, then mediocrity will be the norm. Responsibility must be properly allocated, which is a task of the leaders. No system is successfull without effective leadership.

“If we accept that the formula for quality begins with leadershhip, then the top of the hospital administration must set the expectations for all critical congributors to the ED.

“The essential element of leadership is strong principle.”

These paragraphs define the situation perfectly, in my opinion. However, Steffen and Hevesy must not believe in their validity based on their punitive actions against someone who pointed out to them the problem that needed their attention. And both Steffen and Hevesy told me that there were serious problems with leadership in the

OSF-ER.

On June 3, ‘05, a tiny article appeared in the Journal Star: “Peoria Hospital Opens New Emergency Unit”:

“OSF-SFMC opened its new $2.4 million Emergency Care Unit on Thursday. The 13-bed facility…will serve as an observation area for patients with chest pain, heart failure and asthma.

Mike Cruz, the assistant director of the OSF-ED stated, “It should help significantly…because of the operational components. This will increase total capacity (for emergencies) by about 30 percent. Given that we haven’t had a new facility recently and there has been a volume increase…it will help”.

Notice that it wasn’t Hevesy or Steffen that made this announcement to the public. This needed to happen years before and “the main campus (downtown OSF) had been ignored” according to Dr. Tim Miller in OSF administration when I met with him in September, 2001, after I had written my letter to Steffen.

In April, 2006 when OSF announced its new 234 million dollar campus renovation, Keith Steffen stated that this would include a "much needed" improvement in the Emergency Room which was built for 32,000 patients but is currently expected to have 62,000 visits in 2006.

Why did Mr. Steffen refer to me as a "cancer in the Emergency Department" when I brought the OSF bed capacity problem to his attention in 2001?

OSF’s leadership definitely is lacking, not based on strong principle, and needs a change.

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Annals of Emergency Medicine--September, 2019

Crowding occurs when the identified need for emergency services exceeds available resources for patient care in the emergency department (ED), hospital, or both.

The causes of crowding are multifactorial and span the entire health care delivery system. Research has shown continued growth in ED visits that has outpaced population growth. Current trends show increasing patient acuity, requiring more complex evaluation and treatment plans that increase ED care delivery times, as well as inpatient lengths of stay. The resultant strain on hospital inpatient bed capacity creates downstream pressure to board admitted patients∗ in the ED. These factors exacerbate crowding by using limited ED resources, including beds, nursing care, and access to support services such as radiology and laboratory and environmental services. Evidence has shown an increase in morbidity and mortality because of boarding.

Results of crowding include the following:

• •
   Treatment of patients in areas not designated for treatment, such as hallways, resulting in a loss of privacy for patients and families
• •
   Treatment of boarded patients, including mental health and ICU patients, by ED nurses
• •
   Increased morbidity and mortality for both boarded and ED patients
• •
   Increased disability of older patients who are discharged to facilities rather than admitted
• •
   Increased length of stay for admitted patients
• •
   Decreased patient satisfaction for hospitalized and ED patients
• •
   Diminished ED staff satisfaction and employee engagement
• •
   Significant delay in evaluation and treatment of emergency patients
• •
   Patients leaving before completion of medical treatment
• •
   Increased ambulance diversion time
• •
   Increased stress for behavioral health patients because of a lack of facilities or privacy that is a necessary component of emergency psychiatric care
• •
   Increased costs for care delivery
• •
   Reputation damage for the entire institution

It is the responsibility of hospital leadership and care providers to quantifiably measure, analyze, and address identifiable and recurrent causes of crowding (such as the predictable saturation of inpatient bed capacity and essential support services) to prevent poor outcomes related to crowding. It is recommended that hospital leadership use a crowding-assessment tool to consistently quantify saturation events and analyze data to identify specific mitigation actions that involve the entire hospital. It is imperative that local and national health care systems be active in addressing the more global and systemic causes of crowding, including hospital funding. Emergency medicine leadership should be actively involved in helping to identify successful solutions to crowding at both the local and national levels.