Main Points

• Overcrowded emergency departments threaten patient safety and access to emergency care for everyone – insured and uninsured.
  
• Emergency visits are expected to increase, despite health care reform, as they did in Massachusetts. Emergency visits in America increased to an all-time of nearly 124 million in 2008. [CDC 2010]
  
• The emergency department provides an essential health care safety net for everyone, and that safety net is in jeopardy as more ERs close their doors.
  
• Everyone is only one step away from a medical emergency.

Is there a crisis in the nation’s emergency departments?

• Yes. The majority of the nation’s emergency departments report they are operating “at or over” capacity.
• Crowding threatens the ability of emergency physicians to provide timely patient care and results in prolonged pain and suffering for patients. Two hundred emergency physicians (2007) said they knew of a patient who had died because of the practice of “boarding.”
• Emergency visits hit a new high in 2008 — up to 124 million (from 96.5 million in 1995) or 222 visits a minute in the United States (CDC 2010). This represents a 37-percent increase.
• Emergency visit rates have increased at twice the rate of growth of the U.S. population from 1997 to 2007 (JAMA 2010), and nearly two-thirds of emergency departments are now classified as safety net hospitals — defined as providing a “disproportionate share of services to Medicaid and uninsured patients —-nearly double from 1997.
• Annals of Emergency Medicine in 2007 found the rates of emergency visits by the elderly are increasing more rapidly than any other group, which study authors predict would lead to “catastrophic” overcrowding.

What is causing the crisis?

• The lack of hospital inpatient beds, growing elderly population and nationwide shortages of nurses, physicians, and support staff.
• Uncompensated care. Hospital emergency departments have a federal mandate to care for everyone, regardless of ability to pay but there is no federal provision to pay for that care. CMS has said half of emergency services go uncompensated. Cutbacks in reimbursement from Medicare, Medicaid, and other payers, as well as payment denials from health plans reduce hospital resource capacity.
• The CDC reported that increases in emergency visits reflect overall population growth, as well as increases in the number of seniors with more severe and chronic illnesses.
• It is a myth that people with nonurgent medical conditions are causing crowding. Most people seeking emergency care need to be there and the rest have nowhere else to go. The percentage of people seeking emergency care with nonurgent medical conditions decreased to less than 8 percent in 2007.
• To compensate, hospitals have been forced to operate fewer inpatient beds than they did a decade ago. Between 1990 and 1999, hospitals lost 103,000 staffed inpatient medical/surgical beds and 7,800 ICU beds. As a result, fewer beds are available for admissions from the emergency department, and the health care system no longer has the surge capacity to deal with sudden increases in patients needing care.
• In 2010, two hospitals in Miami, Florida and an emergency department in Cincinnati closed their doors for good because the burden of uncompensated care made continued operation impossible. In addition, St. Vincent’s Hospital in New York City threatened to close, as did United Medical Center in Washington D.C. because of losses sustained by treating so many uninsured or underinsured patients. When an ER closes, patients don’t go away – they simply move to other hospitals, increasing the crowding there.

What is boarding?

• “Boarding” is the cause of gridlock in emergency departments, which leads to crowding and dangerously long wait times. It occurs when hospitals “hold” emergency patients who have been stabilized and admitted to the hospital from the emergency department. It is a controversial practice that is the primary cause of overcrowding and causes patients to undergo unnecessary suffering and indignity, while putting lives at risk.
• When a patient is boarded, emergency physicians and nurses must continue to monitor that patient, preventing them from attending to new emergencies arriving at the hospital.
• The GAO in 2003 said hospitals are not always able to meet the demand for inpatient beds for emergency patients because of financial pressures. Beds that could be used for ER admissions are being reserved for scheduled admissions, such as surgical patients, who generally are more profitable. The GAO also found that less than one-third of hospitals that went on diversion did not cancel any elective procedures to minimize diversion. Some hospitals cited costs and difficulty of recruiting nurses as major barriers to staffing beds.
• A 2004 study in Annals of Emergency Medicine found that hospitals lose about $1.74 million per year each in potential revenue because emergency department beds are blocked by admitted patients, limiting the emergency department's ability to treat new incoming patients.

What are the solutions?

• Implement high-impact, low-cost solutions to address the problem of holding or “boarding” patients, as recommended by an ACEP task force. Recommendations include:
  • Move admitted patients out of the emergency department to inpatient areas. With each unit taking a small number of patients, the burden of boarding is more evenly spread, thus enabling the emergency department to better care for emergencies – without unduly stressing the inpatient units.
  • Coordinate the discharge of hospital patients before 12 noon. Research shows that timely departure from the hospital can significantly improve the flow of patients in emergency departments by making more inpatient beds available to emergency patients.
  • Coordinate the scheduling of elective patients and surgical cases. Studies demonstrate that the uneven influx of elective patients (heaviest early in the week) is a prime contributor to exceeding capacity.
• Enact medical liability reform.
• Effective solutions require a national commitment and recognition that emergency medicine is an essential community service that must be funded. This crisis can only be solved by a concerted effort by hospitals, policymakers, community leaders and health plan payers.