Emergency Physicians Urged to Act Locally to Solve Overcrowding

Karen Dente, MD

March 16, 2007

March 16, 2007 (Las Vegas) -- The release of the Institute of Medicine (IOM) report in June 2006 on the future of emergency care in the United States health system increased awareness of overcrowding in many emergency departments (EDs) and trauma centers across the country -- a concern long known to many EM physicians working at the frontlines of emergency patient care.

Experts at the 13th annual meeting of the American Academy of Emergency Medicine (AAEM) discussed the implications of the IOM report for the community emergency physician. The overload of EDs across the country adversely affects all patients by delaying emergency care.

Brent Asplin, MD, MPH, a member of the IOM's subcommittee for hospital-based emergency care, told session attendees that the committee "pinned the responsibility clearly on the hospital CEOs" but that "it's our job as emergency physicians to get CEOs involved to improve the flow of patients."

Dr. Asplin, who is also emergency department head at Emergency Medicine Regions Hospital in St. Paul, Minnesota, and associate professor and vice chair of the department of emergency medicine at the University of Minnesota Medical School in Minneapolis, strongly urged ED physicians to voice any problems with overcrowding directly to their local hospital administrators.

According to the IOM report, between 1993 and 2003, ED visits in the United States grew 26% to 114 million annually, while the number of EDs decreased by 400 and the number of operating hospital beds decreased by almost 200,000 per year during that same period.

"The biggest take-home message for community emergency physicians is to end the practice of boarding inpatients in the ED," said Dr. Asplin. Delayed boarding of patients who are not immediately sent to an inpatient unit and who require further work-up and monitoring crowd the ED, taking up beds that should be reserved for patients requiring urgent care.

"One way to alleviate the crowding is to divert the patients to observation units," Robert Glatter, MD, FAAEM, attending emergency physician at Lenox Hill Hospital in New York City, told Medscape. "We have to recognize the fact that keeping the patients in the ED for a long work-up delays the next patient getting in the door, often by 3 to 4 hours."

Understaffing by nurses and physicians is seen as another common cause for overcrowding. "We have nurses burning out who are taking care of boarding patients," said Robert McNamara, MD, FAAEM, chairman of the department of emergency medicine at Temple University Medical School in Philadelphia, Pennsylvania.

In an October 2006 letter to the inspector general of the Department of Health and Human Services, Tom Scaletta, MD, FAAEM, president of the AAEM, writes, "Intentional understaffing of emergency physicians by emergency contract holders, a typical consequence of fee-splitting" is an "important problem of overcrowding." The letter was published in the February 2007 issue of The Journal of Emergency Medicine .

"By eliminating fee-splitting" -- a common arrangement seen in emergency medicine in which emergency services contract holders receive 30% or more of the net revenue while providing little more than a scheduling function -- "resources for care delivery can be increased at essentially no additional cost to the general public," Dr. Scaletta said, "and used to fortify emergency physician staffing levels, the primary factor in patient safety."

While AAEM society leaders are urging Congress for more support ($50 million have been provided for uncompensated emergency and trauma care), emergency medicine experts are still facing some big barriers.

"It is our hope that over time, this [IOM report] is going to have some impact on our practice," said Dr. Asplin. "If you are looking for a magic bullet, that isn't in these reports," he said. "It's really rolling up the sleeves that has the greater potential of improving care."

Dr. Asplin is an honorarium speaker for VHA, Inc. The other physicians quoted in this article report no relevant financial relationships.

AAEM 13th Annual Scientific Assembly: Plenary Session Lecture. Presented March 12, 2007.

American Academy of Emergency Medicine on Medscape

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