Emergency department overcrowding in Florida, New York, and Texas.

ABSTRACT

Background. This study was done to determine the incidence, causes, and effects of overcrowding in emergency departments (EDs) in Florida, New York, and Texas.

Methods. Surveys were mailed to a random sample of EDs in Florida, New York, and Texas. Questions included census, area population, frequency and causes of overcrowding, and impact. Causes of overcrowding were ranked on a 5-point scale.

Results. A total of 300 surveys were sent, and 210 (70%) were returned. Overcrowding was reported in 194 EDs (92%): New York (90%), Florida, (92%), and Texas (95%). Causes of ED overcrowding included hospital bed shortage, high medical acuity of patients, increasing patient volume, too few examination spaces, and shortage of RN staff. Overcrowding resulted in death, permanent disability, additional procedures, and increased length of hospitalization.

Conclusion. In this survey of EDs, overcrowding was pervasive. Many factors contribute to ED overcrowding. Poor medical outcomes may occur because of overcrowding.

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NEARLY 5,000 emergency departments (EDs) exist in the United States and provide care for pa dents with emergency medical conditions 24 hours a day, 365 days a year. Florida, New York, and Texas have large populations and nearly 800 of the nation's EDs. Emergency departments function as a public "safety net," providing care to patients who have unexpected illness or injury that may result in death, disability, or severe pain if not cared for immediately. There has been increasing discussion regarding the ability of EDs to provide timely care to patients with emergency medical conditions. (1-4) A study of California EDs found that 90% had overcrowded conditions and that this problem was shared in both urban and rural areas of that state. (5) The inability to provide timely service results from overcrowded conditions and has been implicated in poor Outcomes for patients with certain medical problems. Anecdotal evidence suggests that patients are subject to longer delays compared with many years ago. The New York State Department of Health has investigated some hospitals in recent years over incidents in which prolonged waits for patients have led to poor outcomes. (6)

Although overcrowding has been the topic of discussion among many emergency physicians, the lay press, and legislators, few scientific studies actually document and analyze the problems. (7) Overcrowding in EDs in some metropolitan academic centers was described more than 8 years (8-11) is also an international problem affecting countries with socialized health care and extensive primary care networks. (12,13) Recently, several articles in the lay press have brought attention to the problem, but despite dramatic headlines and photos of congested EDs, these have been largely ignored by the state and federal government and health care policy makers. (14, 15) A national study was recently conducted that found significant overcrowding but did not analyze the data by state or determine outcomes of patients subject to long waiting times. (16) In addition, questions have been raised that attribute ED overcrowding to states experiencing high growth rates or having disproportionate numbers of elderly persons. To furth er investigate the factors associated with overcrowding and to compare and contrast "sunbelt" states and a large stable northern state, we conducted a survey study of EDs in Florida, New York, and Texas.

METHODS

During the spring of 2000, surveys were mailed to a sample of ED directors (identified from a list published by the American Hospital Association) in Florida, New York, and Texas. Approximately one in three EDs were randomly selected by computed algorithm. A total of 300 surveys were sent (79 in Florida, 119 in New York, and 102 in Texas). A teaching hospital was defined as one having an associated residency program approved by the Accreditation Council for Graduate Medical Education. Specialty hospitals, such as pediatric and psychiatric, were not included. The definition of a private hospital included all other types of facilities, such as for-profit community and health maintenance organization (HMO) hospitals.

The survey included questions regarding regional population demographics, annual ED census, and ED bed capacity. Additional questions inquired whether overcrowding was ever a problem at the particular ED, and if so, how often it occurred. The ED directors were asked to estimate the impact of overcrowding on patients coming to the ED in terms of long waits, delayed diagnosis and treatment, risk for poor outcomes, and actual poor outcomes. They were also asked to rank causes of ED overcrowding on a 5-point Likert scale: 1 = not a cause; 2= minor; 3= somewhat; 4= major; 5= severe. Possible perceived causes included (1) increasing ED volume, (2) increasing severity of patients' conditions, (3) managed care issues, (4) insufficient ED space, (5) nursing shortage, (6) physician shortage, (7) radiology delays, (8) laboratory delays, (9) delays in consultation, and (10) hospital bed shortage. Emergency department directors were also asked to characterize overcrowding from a list of circumstances they believed best de fined overcrowding. Choices provided were as follows: (1) patients wait >30 minutes to see a physician; (2) patients wait >60 minutes to see a physician; (3) all ED beds are filled >6 hours/day; (4) patients are placed in hallways >6 hours/day; (5) physicians feel rushed >6 hours/day. Respondents were also provided the opportunity to write in other definitions of overcrowding. The study was approved by our institution's human subjects review committee as meeting federal exemption from informed consent.

RESULTS

Of 300 EDs surveyed, 210 (70%) responded, and 194 (92%) reported that overcrowding was a problem. Of the 210 completed surveys, 143 came from private, community, or HMO hospitals and 67 from teaching or county hospitals. The number of EDs reporting overcrowding by state was 50 of 54 (93%) in Florida; 79 of 88 (90%) in New York, and 65 of 68 (95%) in Texas. Two thirds (68%) of EDs reported that overcrowded conditions had developed within the past 5 years.

Overcrowding was most common in urban areas in all three states serving populations greater than 500,000 (Table 1). Fewer, but still a significant number of rural hospitals serving populations under 50,000, reported ED overcrowding, with a range from 76% (New York) to 91% (Florida). Teaching hospitals experienced more overcrowding than nonteaching hospitals (Table 1). Only 16 EDs reported no problem with overcrowding, and 13 of them were private facilities or those affiliated with communities and located in smaller communities serving populations less than 500,000.

Agreement on the definition of overcrowding was shared by responding EDs. The proportions that considered the following circumstances as defining ED overcrowding were as follows: all ED beds filled >6 hours per day (80%), patients on gurneys in hallways >6 hours per day (81%), physicians so rushed they may make errors >6 hours per day (75%), 10 patients who have waited at least 3 hours to see a physician in any one day (75%). Responses between private and community or HMO and university or county ED directors were similar. Sixty-four percent of the directors estimated that overcrowding occurred several times per week, and 28% of them reported daily overcrowding, mostly between 3 and 11 PM.

The reasons the EDs gave for the perceived overcrowding are listed in Table 2 and are similar for the three states, except that those in New York reported less overall increased patient volume as a cause of overcrowding. Among the three states, hospital bed shortages and increased severity of conditions treated were the most common problems. Many EDs reported delays in diagnosis and treatment. Several EDs reported these delays put patients at risk for poor outcomes and that poor outcomes actually occurred as a result of overcrowding. The ED directors also provided actual examples of poor outcomes, such as delays in administration of thrombolytic drugs after acute myocardial infarction (Table 3).

DISCUSSION

In this study, ED directors overwhelmingly reported overcrowding as a problem in all three states. In contrast to earlier studies, the problem is apparently not only limited to county and teaching hospitals, but also affects private hospitals. (17) Discussion in the early 1990s provided evidence that overcrowding was primarily limited to teaching and county hospitals serving cities and urban areas. (6,18) Most of the EDs serving communities of less than 500,000 reported overcrowding.

No simple definition exists to accurately describe overcrowding, since the reasons for it are complex. The finding that all three states had nearly equal problems with overcrowding is not surprising, even though these states have different demographics. From 1990 to 2000, the population of Florida increased from 12,937,926 to 15,982,378, that of New York increased from 17,990,445 to 18,976,457, and that of Texas from 16,986,510 to 20,851,820. (19) Florida has a large elderly population who have existing health care plans and could visit their primary health care provider to avoid ED visits. New York has a large immigrant population who may use EDs as their primary source of health care because of lack of insurance or knowledge of the US health care system. Texas also has a large population of immigrants, but Texas is booming and has good economic growth and access to primary health care.

The findings of our study suggest overcrowding is due to more complex and multifactorial causes. In addition to the causes listed in Table 2, other factors may be involved, such as inefficiency in providing medical care, language translation problems, increasing numbers of uninsured patients who have no other place to turn for medical care, a relative decline in the number of inpatient hospital beds leading to patients staying in the ED, increasing standard of care in the ED leading to more diagnostic studies, or problems with access to primary care for patients with and without insurance plans. (1) Many of the factors leading to delays in patient care are associated with services beyond the control of the ED (Table 2). One of the most cited contributors to overcrowding was shortage of hospital beds. When all hospital beds are full, patients who need admission must wait in the ED. This may limit their evaluation and treatment. As the population ages and life expectancy increases, a higher number of patients with several concomitant medical problems, such as congestive heart failure and chronic obstructive pulmonary disease, will be seen in EDs. This is thought to be a major contributor to overcrowding. Another factor cited was the increasing volume of patients. As the population of Florida, New York, and Texas grows, the demand on emergency services will grow accordingly. In the early 1990s, shortages of nursing staff in EDs were thought to be a major contributor to overcrowding. (9) Nursing, laboratory, and radiology services in university or county hospitals are frequently overused and understaffed. Several directors also commented on the survey forms that overcrowded conditions in the ED were damaging morale of nursing and physician staff.

Some ED directors reported that issues with managed care were a factor in overcrowding. Florida has led the three states in the development of managed care systems. Managed care and HMOs discourage patients from using emergency services. (20) Several organizations have refused or delayed payments to EDs. Managed care "gatekeepers" may call the ED and demand to speak with the emergency physician before authorizing care for a patient. This reduces the time emergency physicians are able to spend caring for patients.

Long waiting times cause frustration and may prolong pain and suffering. Delays may also occur in the diagnosis and treatment of serious medical conditions. The poor outcomes cited by EDs are an unfortunate result of overcrowding. The finding of poor outcomes was not surprising, since a case example has been previously described. (21)

This study has several limitations. The answers to the survey questions reflect the knowledge, experience, and opinion of the directors who responded and may have led to an overestimation of the problem. We assumed that directors have a good sense of how their EDs operate. We did not ask for verification of their response. Causes of overcrowding were measured using an integer scale with adjectival descriptions, such as minor, moderate, and major, which may represent only a perception of the overcrowding problem.

SUMMARY

In this study, ED overcrowding was pervasive in Florida, New York, and Texas. According to ED directors, many factors contribute to overcrowding. In addition, poor patient outcomes may occur because of overcrowding.

TABLE 1

Emergency Departments Reporting Overcrowding and Differences Between
States

                          Florida   New York   Texas      Total
                          (n = 54)  (n = 88)  (n = 68)  (n = 210)
                           No.(%)    No.(%)    No.(%)    No.(%)

Number overcrowded        50 (92)   79 (90)   65 (95)   194 (92)
Population served
   Urban (>500,000)       24 (96)   47 (98)   23 (96)    94 (97)
   50,000-500,000         14 (93)   21 (95)   14 (93)    49 (94)
   Rural (<50,000)        10 (91)   19 (76)   22 (88)    51 (83)

Facility type
   Teaching/county        15 (100)  34 (94)   15 (94)    64 (96)
   Private/community/HMO  35 (90)   45 (87)   50 (96)   130 (91)
TABLE 2

Causes of Overcrowding in Emergency Departments (EDs)

                           Florida           New York

Hospital bed shortage  4.4 [+ or -] 1.1  4.5 [+ or -] 1.1
Increased severity of
 patient's condition   4.2 [+ or -] 0.8  4.1 [+ or -] 1.0
Increased ED volume    4.6 [+ or -] 0.7  3.3 [+ or -] 1.1
ED space limitations   3.7 [+ or -] 1.1  3.1 [+ or -] 1.2
Nursing shortage       3.7 [+ or -] 1.0  3.6 [+ or -] 1.2
Radiology delays       3.9 [+ or -] 1.2  3.2 [+ or -] 1.3
Consultation delays    3.4 [+ or -] 1.2  3.3 [+ or -] 1.2

                            Texas

Hospital bed shortage  4.0 [+ or -] 1.2
Increased severity of
 patient's condition   4.1 [+ or -] 1.0
Increased ED volume    4.2 [+ or -] 1.0
ED space limitations   4.0 [+ or -] 1.2
Nursing shortage       3.3 [+ or -] 1.4
Radiology delays       3.6 [+ or -] 1.4
Consultation delays    2.8 [+ or -] 1.2
TABLE 3

Poor Outcomes From Overcrowding


Delayed therapy for acute myocardial infarction
Delayed therapy for thrombotic cerebrovascular accident
Sepsis in patients with appendicitis
Delayed diagnosis of sepsis in pediatric patient
Delayed treatment of intracranial hemorrhage
Death from delay in evaluation of incarcerated hernia
Intubation and prolonged intensive care unit stay in delayed asthma
 treatment

References

(1.) Derlet RW, Richards JR: Overcrowding in the nation's emergency departments: complex causes and disturbing effects. Ann Emerg Med 2000; 35:63-67

(2.) Eisenberg D: Critical condition. Time. January 31, 2000, pp 52-54

(3.) Avila J: Interview: Emergency Room Overcrowding. NBC, January 9, 2001

(4.) SoRelle R: The witching hour: overcrowded emergency departments. Emerg Med News 1992; 21:40-41

(5.) Richards JR, Navarro ML, Derlet RW: Survey of directors of emergency departments in California on overcrowding. West J Med 2000; 172:385-388

(6.) Henry MC: Overcrowding in America's emergency departments: inpatient wards replace emergency care. Acad Emerg Med 2001; 8:188-189

(7.) Kellermann AL: Deja vu. Ann Emerg Med 2000; 35:83-85

(8.) Andrulis DP, Kellermann A, Hintz EA, et al: Emergency departments and crowding in United States teaching hospitals. Ann Emerg Med 1991; 20:980-986

(9.) American College of Emergency Physicians, Task Force on Overcrowding: Measures to deal with emergency department overcrowding. Ann Emerg Med 1990; 19:944-945

(10.) Lynn SG, Kellerman AL: Critical decision making: managing the emergency department in an overcrowded hospital. Ann Emerg Med 1991; 20:287-292

(11.) Kellermann AL: Too sick to wait. JAMA 1991; 266:8

(12.) Shih FS, Huei-Ming M, Chen SC, et al: ED overcrowding strategies. Am J Emerg Med 1999; 17:198-202

(13.) Boyle P, Pineault R, Roberge D: Assessing Quebec's multicomponent program to reduce emergency room overcrowding. Canadian Public Policy--Analyse de Politiques. 1992; XVIII:189-202

(14.) Spiegel C, Wielawski I: Two investigations set on overcrowding of emergency room: California State and Los Angeles County investigation of conditions of County--USC Medical Center. Los Angeles Times 1991; 111:B3

(15.) Orenstein JB: Overcrowded emergency rooms are in critical condition. Sacramento Bee, Section B, page B7, May 7, 2001

(16.) Derlet R, Richards JR, Kravitz RL: Frequent overcrowding in US emergency departments. Acad Emerg Med 2001; 8:151-155

(17.) Grumbach K, Keane D, Bindman A: Primary care and public emergency department overcrowding. Am J Public Health 1993; 83:372-377

(18.) Derlet RW: Overcrowding in the ED. J Emerg Med 1992; 10:93-94

(19.) US Census Bureau: 1990 and 2000, State Census, 2001. http://www.census.gov

(20.) Derlet RW, Young GP: Managed care and emergency medicine: conflicts, federal law, and California legislation. Ann Emerg Med 1997; 30:292-300

(21.) Thompson J: CAEP issues--coroners and lack of emergency department resources. J Emerg Med 1999; 17:541-542

RELATED ARTICLE: KEY POINTS

* Emergency department (ED) overcrowding is an equally serious problem in Florida, New York, and Texas.

* Multiple factors are responsible for ED overcrowding.

* Adverse patient outcomes result from ED overcrowding.

* Overcrowding is not only limited to urban EDs, but it also occurs in rural areas.

From the Division of Emergency Medicine, University of California Davis Medical Center.

Reprint requests to Robert W. Derlet, MD, University of California Davis Medical Center, Division of Emergency Medicine, 2315 Stockton Blvd. PSSB 2100, Sacramento, CA 95817.