Most experts predict higher ED volumes

Many strategies available to minimize logjams

The bad news: Most ED experts believe that health care reform will only exacerbate the steady growth of volume in the nation's EDs. The good news: ED managers have several weapons in their arsenals to help keep patients flowing through and out of their departments.

There are two forces at work that indicate crowding will become an even greater problem in the future, says Charles L. Reese IV, MD, FACEP, chair of the department of emergency medicine for the Christiana Care Health System in Newark, DE.

"There is a gradual reduction in availability of primary care services of all kinds, with fewer medical students choosing primary care and very few internal medicine people going into primary care, while those who are in it are retiring and getting older and have a much more difficult time making a living than in the past," Reese says. "Combine that with an aging population and increasing complexity in their medical problems, and both those forces favor more patients going to the ED."

The final dynamic, he notes, is empirical evidence coming out of Massachusetts, which passed health care reform of its own. "We've seen a very substantial increase in the number of patients going to their EDs," Reese says. "This indicates to me substantial pent-up demand being unleashed by people having the ability for their health care to be paid for."

David C. Seaberg, MD, FACEP, dean and professor of emergency medicine at the University of Tennessee College of Medicine in Chattanooga and an ED physician with the Erlanger Health System, also in Chattanooga, agrees with Reese. "Reform was about insurance, not access," Seaberg says. "We don't have enough primary care doctors." He says the true impact of reform will start to be seen once the health exchanges are set up.

"If you look at what's happened in Massachusetts, it's a microcosm of what may happen in the country," Seaberg says. "With 97% of the people having some form of insurance, you see ED visits going up 7%-9%, while the average for the rest of the country is 1% to 1.5%."

Reimbursement rates under reform also could impact ED crowding, says Lynn Massingale, MD, FACEP, chairman and CEO of TeamHealth, a Knoxville, TN-based clinical outsourcing firm that provides ED services to more than 400 hospitals nationwide. "For the currently uninsured, it will probably be nothing above Medicare and perhaps more like Medicaid," notes Massingale, who points out that there are so few doctors in communities now who will take Medicaid and not a lot who take new Medicare patients. "So those who have 'insurance' will not have access because there's not enough capacity in primary care practices." Impact also could be felt from subspecialties, he adds. "We know from seeing patients in the ED that many women are not getting pap smears, breast exams, or mammography because there's no place for them," he says.

What's more, the nurse practitioners in drug store clinics are not really adding net new capacity because "they're just in a new location," he says.

Another challenge under reform is how, and how aggressively, to address the issue of acuity, observers say.

"Low-acuity patients are not our problem; sicker patients are," says Reese. "In our own institution we see 25,000 a year, but we designed a very good low-acuity care model using two or three rooms to process those people." The real issue, he says, is patients with Emergency Severity Index scores of 1, 2, and 3, which he predicts will increase.

The recently released "National Hospital Ambulatory Medical Care Survey: 2007 Emergency Department Summary," from the Centers for Disease Control and Prevention (CDC), supports Reese's contention by showing that only 7.9% of all visits were non-urgent — down from 12.1% in 2006, says Angela F. Gardner, MD, FACEP, president of the American College of Emergency Physicians (ACEP) and assistant professor, division of emergency medicine, department of surgery at the University of Texas Southwestern Medical Center in Dallas.

"One of the concerns ACEP has is that the administration may have based all its assumptions on a faulty premise: that they can decrease the amount of ED visits by improving primary care," Gardner says. "What we're predicting will happen is that EDs will grow busier and busier, and the CDC data support that based on its preliminary report for 2008."

However, Seaberg says that Erlanger was sufficiently concerned with non-urgent pediatric patients that it established a federally qualified health center (FQHC) on campus to relieve the burden on the ED at T.C. Thompson Children's Hospital at Erlanger.

Other strategies can free space

There are several strategies ED managers can employ to combat the anticipated volume increases that reform will bring, Gardner says.

"The biggest thing we have to promote in the college is to ask the ED manager to get admitted patients out of the ED, which allows us the flexibility to see more patients," she says.

One strategy is to take those patients to a floor even before a bed is ready, Gardner says. "Floor nurses don't like that. They want the patients all tucked in their bed. But the patient probably gets better care on the hospital floor than in the hall of the ED," she says.

Of course, such a policy requires the agreement and backup of administration. How can the ED manager "sell" it? "You get more patients through your ED," says Gardner. "Obviously, you do not want to do that if you don't have a waiting line to get into your ED, but that's a rare occurrence." She points out that if there are 10 patients taking up half the ED's beds, two each can go to five floors (one on each wing). Not only will that movement relieve the ED, she says, but "if you put a patient on the floor in a bed, they will find a way to take care of that patient. They will find a bed."

Gardner recommends having a strategy in place for when your ED becomes too crowded. "Just that act brings attention to the issue and helps people resolve the problem," she says. "I've seen a number of hospitals develop these full-bed protocols."

Such protocols involve administration, nursing leaders, and the ED medical director, Gardner says. "The protocol is triggered at a certain point, and they come down to the ED and determine who needs to be admitted and where they can be put," she says. "You consider which patients can be discharged or can wait in another area. Just shining the light on it will cause solutions to come up."

ED managers need to make their hospital administrators aware of how they can help reduce boarding and crowding in the ED, adds Seaberg. "ACEP put out a paper a couple of years ago on solutions to ED boarding, and three of the main ones don't even involve the ED," he says. Those solutions include moving patients into floor hallways, smoothing the elective surgery schedule, and discharging admitted patients before noon, he says. (The ACEP publication on boarding solutions can be downloaded for free at

How do you get administration on board? "Show them the Massachusetts data," Seaberg suggests. "Ask them to think about what a potential 7%-9% increase in volume would do." If they care about their customer services and patient safety scores and metrics, they will have to look at how to deal with these issues, he says.