GEORGE CLOONEY'S challenges make for good TV. While the former star of "ER" struggles with romance and fictional patients,
much of the drama in today's emergency department (ED) centers around the very real problems of overcrowding, increased utilization
and increased wait times. To address the problem, players across the healthcare spectrum are working on piecemeal solutions,
including enhanced triage, alternative care sites and access to primary care and disease management.
The problem facing today's EDs is one of simple supply and demand. On the supply side, the United States experienced a loss
of 425 hospitals with emergency departments between 1993 and 2003, according to the Institute of Medicine's three-volume Future of Emergency Care report. That represented a 9% decrease in the number of EDs serving the population. At the same time, hospital closures reduced
inpatient capacity by about 198,000 beds. This sharp decline in capacity was largely in response to cost-cutting measures,
lower reimbursements by payers, shorter lengths of stay and reduced admissions under evolving care models.
Who is using the ED?
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During the same period, the population of the United States grew by 12%. As the population aged and more people were diagnosed
with chronic conditions, hospital admissions increased by 13%. Visits to the ED spiked as well: Between 1993 and 2003, ED
visits increased 26%. Today roughly 115 million patients access an ED annually and, often because of delaying care, they're
sicker and require more treatment.
Not surprisingly, that means an increasing number of patients require admission to the hospital. Nationwide, about 13.9% of
ED patients were admitted to the hospital in 2003, according to the IOM report. That represents about 43% of all hospital
patients. ADMISSION BOTTLENECK
Unfortunately, the transition from the ED to a unit is often not a smooth one. Given the decrease in the number of hospital
beds and the fact that elective admissions are more profitable than ED admissions, there's often a bottleneck between the
ED and the main floors of the hospital. As a result, patients who need care are often "boarded" in the ED until a bed becomes
available. Because boarded patients consume ED resources, EDs quickly become overcrowded. Waiting times increase and patients
may be diverted to other hospitals.
A Government Accountability Office (GAO) study found that in 2001, 90% of hospitals boarded patients for at least two hours,
and about 20% of hospitals reported an average boarding time of eight hours. It is not unusual for patients in a busy hospital
to board for up to 24 or even 48 hours.
A study published in Health Affairs in January evaluated the change in wait time from 1997 to 2004 for adult ED patients. Harvard Medical School researchers
at the Cambridge Health Alliance found that the median ED wait time went up from 22 minutes in 1997 to 30 minutes in 2004,
a 36% increase. For patients diagnosed in the ED with acute myocardial infarction, or heart attack, the median wait time increased
15%, from 8 minutes in 1997 to 20 minutes in 2004. And for those identified in ED triage as needing attention "emergently,"
wait times increased from 10 minutes in 1997 to 14 minutes in 2004, an increase of 4% .
