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NEJM-Catalyst: Emergency Department Crowding: The Canary in the Health Care System

30 Sep 2021 10:36 PM | Matt Zavadsky (Administrator)

This a VERY WELL-DONE, research and evidence-based commentary on the cause, effect, and recommended SOLUTIONS to ED overcrowding.

It’s a bit long, but well worth the read!  A PDF of the commentary is attached.

All facets of the healthcare system, including EMS, need to work together to appropriately navigate patients, especially those who access healthcare through ‘911’, through effective integration.

Tip of the hat to Rob Lawrence for sharing this article!


Emergency Department Crowding: The Canary in the Health Care System

The solution for this serious threat to ED staff and harm to patients cannot come from a single department, but through engagement of and ongoing commitment by leaders throughout the hospital and, more broadly, by those in the payer and regulatory segments of the health care system as well.

September 28, 2021

By: Gabor D. Kelen, MD, Richard Wolfe, MD, Gail D’Onofrio, MD, MS, Angela M. Mills, MD, Deborah Diercks, MD, Susan A. Stern, MD, Michael C. Wadman, MD & Peter E. Sokolove, MD


The impact of ED crowding on morbidity, mortality, medical error, staff burnout, and excessive cost is well documented but remains largely underappreciated.

Among the most notable content in the commentary:

Emergency department crowding is a sentinel indicator of health system functioning. While often dismissed as mere inconvenience for patients, impact of ED crowding on avoidable patient morbidity and mortality is well documented but remains largely underappreciated. The physical and moral harm experienced by ED staff is also substantial. Often seen as a local ED problem, the cause of ED crowding is misaligned health care economics that pressures hospitals to maintain inefficient high inpatient census levels, often preferencing high-margin patients. The resultant back-up of admissions in the ED concentrates patient safety risks there. Few efforts (even well-meaning ones) address the economically driven root causes of ED crowding, i.e., the need to achieve minimal financial hospital margins. The key to a sustainable solution is to realign health care financing to allow hospitals to keep inpatient capacity below a critical threshold of 90%; beyond that, hospital throughput dynamics will inevitably lead to ED crowding.

Even prior to the Covid-19 pandemic, greater than 90% of U.S. EDs found themselves stressed beyond the breaking point at least some of the time. Many remain overwhelmed daily.

The authors provide detailed commentary on:

  • Causes of Crowding and Why ED Crowding Persists
    • Health System Incentive Structure
    • Insufficient Health Care Capacity
    • Failure of Regulatory Agencies, Payers, and Legislative Bodies
    • Misunderstanding of the Issue
  • Solutions:
    • ED Input Solutions
      • Distinct from individual hospitals placing themselves on ambulance diversion is a new voluntary 5-year payment model by the Centers for Medicare & Medicaid Services (CMS): Emergency Triage, Treat, and Transport ET3 for Medicare fee-for-service beneficiaries calling 911. In this model, CMS will pay participants to transport to an alternative destination partner, including primary care offices, UCCs, or even community mental health centers. In and of itself, ideally, only low-acuity patients would be transported to other settings and, thus, no significant impact on ED crowding from boarding is expected. Indeed, we have apprehension about Medicare patients being sent by ambulance to nonemergency care settings given the occult medical vulnerabilities of such patients and the high rates of needed hospital admission associated with ambulance transports.
  • ED Throughput Solutions
    • Hospital Solutions to Relieve Access Block (Output)

The authors recommend five essential elements to take on overcrowding in the ED:

  1. ED crowding must be acknowledged as the serious problem to patient safety that it is — and not the “inconvenience” it is perceived to be.
  2. Most important, there are no known examples of successful amelioration of ED crowding in any institution without significant visible buy-in and action directed from senior-most institutional leadership. This commitment must be continuously evident with incentives of management at all levels throughout the institution and aligned to resolve this most important patient safety concern.
  3. Many institutions operate on razor-thin margins. Health care financing must realign reimbursement from current practices that outright promotes ED boarding.
  4. Regulators such as TJC and CMS must clearly address the impact of crowding on patient safety, its potentiation of violence, and its implications for staff well-being; likewise, the Accreditation Council for Graduate Medical Education should consider the impact of crowding on training and trainee well-being within their credentialling criteria of institutions. The regulations should include clear metrics and associated penalties/consequences.
  5. Crowding is predictive and, accordingly, enforceable preemptive surge plans must be generated and actuated. When crowding does occur, it must be considered in the same light as a disaster with the same deliberate moral response.

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