By Laura Stokowski, RN, MS

"Emergency department crowding" evokes visions of rows of people in rigid plastic chairs: coughing, moaning, or holding towels to their wounds, anxious faces turning each time the door opens, eager for the summons that will bring them to the coveted inner sanctum of the emergency department (ED) where blessed relief awaits them. Inconvenient and frustrating, to be sure, but hardly a crisis.

If only ED crowding was as simple as a few extra patients in the waiting room...or a slightly longer wait. But the problem of ED crowding is complex and far-reaching, affecting the entire emergency care system, from pre-hospital to post-emergency care. Although it is receiving a great deal of attention from many quarters, crowding continues to occur in the nation's EDs, where nurses are doing their best to cope in environments that are dramatically different from those to which they are accustomed.

The Real Problem of Crowding

Contrary to its name, ED crowding is not an ED problem; it is a systemic, or hospital, issue.[1] A crowded hospital is the true source of a crowded ED. Strictly speaking, crowding describes a situation when the identified need for emergency services outstrips the available resources.[1] Crowding is a function of patient volume, patient acuity, physical space, and the number of on-duty staff.[2]

The problem starts with a mismatch in demand and supply. From 1994 to 2004, ED visits increased from 93 to 110 million annually in the United States, an increase of 12%. But in the same 10-year span, the number of hospital EDs fell by 18%, forcing the remaining hospitals to absorb the excess patient load. Furthermore, the aging of the population and increasing rates of chronic illness are bringing sicker patients to the ED than ever before.[3]

Against this backdrop of higher volume-higher acuity, additional factors have come into play to create gridlock in the ED. It was formerly believed that ED crowding was caused by a growing volume of ED visits by people who were uninsured or had Medicaid and were using the ED to be seen for nonurgent conditions.[2] It is now recognized that the real bottleneck in the hospital is the operating room. Many surgeries are scheduled for Tuesdays, Wednesdays, and Thursdays, filling inpatient intensive care units (ICUs) and medical-surgical unit beds on those days. When beds are needed for patients from the ED, they are unavailable and these acutely ill patients start backing up in the ED.

Eventually, the ED is full and, unable to take any more patients, and must place ambulances on divert to other area EDs. Walk-in patients are subject to extremely long waits, and many leave the ED without being seen.

 

In a Holding Pattern

The nurse manager of an academic medical center ED recently oversaw an expansion of her department from 25 to 53 beds. "All we did was become the largest med-surg unit in the hospital 3 days a week," she said (Donna Mason; personal communication; March 10, 2007).

This illustrates the greatest ED nursing problem generated by hospital crowding: the necessity to hold, or board, patients in the ED who require admission to the hospital but for whom there are no available beds on inpatient units. "Holding" and "boarding" are terms used interchangeably to describe the practice of providing continued care for a patient within the ED after a decision to admit or transfer has been made.[4] As pointed out in a recent report by the Institute of Medicine, however, the term 'boarder' is a misnomer because it implies that these patients require little care.[3] The truth is, they are often the sickest, most complex patients in the ED, which is why they need to be admitted to the hospital.[3] By occupying beds and nursing time in the ED, boarders prevent new patients from being admitted into the ED.[2]

The problem of boarding is nationwide. A survey conducted in a cross-section of ospitals throughout the country on a typical Monday evening found that 73% of hospitals were boarding at least 2 patients.[5] Kathleen A. Ream, Washington Representative of the

Emergency Nurses Association (ENA) frequently talks to nurses from around the United States about patients being boarded for up to 24 hours in the ED. "We believe it is unacceptable because it is not in the best interest of patients," states Ream of the ENA's position on boarding or holding in the ED.

Holding or boarding in many EDs often takes place in non-treatment areas such as hallways, conference rooms, offices, and even shower stalls because there are simply too few rooms.[5] These areas lack equipment and outlets necessary for patient care requirements. Family members are unable to remain with the patient the same way they would in an inpatient room. Even when ED rooms are available, there are no attached bathrooms, greatly hindering patient privacy.

Patient confidentiality can be threatened in other ways when EDs are crowded. Some EDs become so full, and patient waits so long, that emergency nurses have begun providing care right in the waiting room (Donna Mason; personal communication; March 10, 2007). Diagnostic tests, such as radiographs and laboratory work have been obtained, and basic interventions such as intravenous therapy and breathing treatments have been provided to patients in the waiting room because no beds were available in which to put them.

Working Outside of the Comfort Zone

ED nurses, by nature of their work, have a broad knowledge base. They routinely care for patients ranging from newborns to the elderly, a daunting responsibility given the variability between various age groups in normal vital signs, laboratory values, medication dosages, and so forth. Emergency nurses must maintain competence in providing care for all trauma, urgent, and nonurgent health problems that present in the ED. Furthermore, these nurses usually do not have access to complete medical records or patient histories.

Nonetheless, because care in the ED is ordinarily acute and episodic, nurses are able to provide safe care to the full spectrum of patient types and problems encountered in the ED. As a rule, emergency nurses enjoy the rapid turnover of patients and the swiftly changing environment. In fact, it is "the pace that gives the pleasure," notes ENA President Donna Mason.

Mason explains further that the routine practice of boarding patients in the ED when inpatient beds are full has forced emergency nurses to adopt 2 different ways of practicing nursing, often simultaneously. A nurse might have a patient load comprising 2 typical ED patients, along with 2 boarders. The type of care required by boarders can be dramatically different from that required by ED patients. Scheduled medications, pulmonary hygiene, maintenance of intravascular catheters, and bathing patients are only a few of the routine nursing interventions that ED nurses are not used to, but must perform when caring for boarded patients.

"Their number one concern is not being able to provide the kind of care they know patients should be receiving," says Kathi Ream, describing the sheer frustration felt by emergency nurses. Their frustration is understandable, for unfamiliarity with patient care requirements does not provide a rationale for failing to provide safe, quality care for boarded patients. The Joint Commission of Healthcare Organizations addresses care for boarded patients by stating that "patients with comparable needs receive the same standard of care, treatment, and services throughout the hospital."[6] Similarly, in their position statement, Holding Patients in the Emergency Department, the ENA states that "patients held in the emergency department must be provided the same level of care they would receive in inpatient units if their discharge from the emergency department is delayed."[4]

And, not surprisingly, safety problems can arise as a result of boarding or holding in the ED. The most common of these tend to be errors of omission, such as forgetting to give scheduled medications or treatments, or failing to complete required assessments such as those for skin, nutrition, or fall risk. "Emergency nurses just aren't geared to the routines of med-surg nursing," explains Donna Mason.

This situation creates difficulties for the recruitment and retention of emergency nurses, according to Mason. "Holding is the number one reason nurses leave the ED. They love what they do, but they don't want to be med-surg nurses or ICU nurses." The issue also surfaces when Mason interviews nurses for vacant positions in the ED. "The first things they ask are, how often do you hold, and how many patients do you hold?" Mason has recently taken the unusual step of hiring med-surg nurses to care for boarded patients in her ED to relieve some of the strain on the emergency nursing staff.

There is 1 bright spot. Mason has found that for once, she has no trouble staffing the ED on the weekends. Emergency nurses actually prefer working weekends, but it isn't because of higher pay differentials. On weekends, the ED reverts to normal because there are no elective admissions on the medical-surgical units, therefore fewer boarded patients in the ED.

 

Long Waits and Violent Behavior

An inevitable consequence of hospital crowding is that patients in the emergency department must wait longer to be seen. Prolonged waiting and crowded or unsatisfactory waiting room conditions can lead to verbal expressions of anger and frustration or even physical assaults upon healthcare workers.[7]

It is believed that the majority of abusive incidents perpetrated by patients, family, and visitors toward ED nurses are never reported through usual hospital channels.[8] Some limited data, however, are available indicating that very high levels of assault and abuse are directed at ED nurses. In a 2002 study, 100% of ED nurses surveyed reported having been verbally assaulted and 82.1% reported having been physically assaulted within the preceding year. Among the most common reasons cited for abusive behavior directed toward nurses was anger related to long wait times.[9]

A high prevalence of violence directed toward ED nurses was confirmed in a survey of ENA members in 2006. Eighty-six percent of ED nurses reported having been the victim of violence by a patient or a patient's family member when working in the ED. More than 40% of respondents felt only somewhat safe or not safe at all at work.[8]

Because the problem of crowding is not likely to be solved quickly, nurses and other emergency providers will continue to be vulnerable to workplace violence related to dissatisfaction with the healthcare system. The ENA has addressed this problem in detail and emphasizes that "health care organizations must take preventive measures to circumvent workplace violence and ensure the safety of all health care workers, their patients, and visitors."[10]

 

What Does the Future Hold?

What will it take to return the ED to its former status as the place we depend on to treat urgent medical conditions and manage trauma -- promptly, safely and competently -- any hour of the day or night, every day of the week?

Many believe it will take an entirely new emergency care system, one that corrects the inefficiencies and fragmentation of the current system. The emergency care system of the future should be coordinated, regionalized, and accountable.[11] Coordinated, in the sense that from the patient's point of view, the delivery of emergency services is seamless. Regionalized, in the sense that hospitals, emergency medical service providers, and others work as a unit to provide services to everyone within a single region. And accountable, meaning there will development of well-defined standards and ways of measuring performance against those standards and reporting them to the public.[11]

In the meantime, hospitals must find internal solutions to ease the problem of crowding in the hospital that seriously affects the ability of the ED to function normally. "Some hospitals are very enlightened," according to Kathi Ream. "Ambulance diversion is not acceptable to them. If the hospital administration is not behind the issue that crowding is unacceptable, you are not going to get the relief that you need. Even little things can help, like having cleaning crews on hand to clean your rooms immediately when you discharge patients."

ED nurses are critical to the emergency care system of the future. I am certain that I am not alone in hoping that they can weather the storm in which they now find themselves, and in offering my sincere gratitude to them for facing this arduous challenge.

 

Editor's Note -- About the Emergency Nurses Association

The Emergency Nurses Association (ENA) is the only professional nursing association dedicated to defining the future of emergency nursing and emergency care through advocacy, expertise, innovation, and leadership. Founded in 1970, ENA serves as the voice of more than 32,000 members and their patients through research, publications, professional development, injury prevention, and patient education. Additional information is available at ENA's Web site, at www.ena.org.

 

References

   1. American College of Emergency Physicians. Emergency Department

Crowding. 2004. Available at:

http://www.acep.org/webportal/PracticeResources/issues/crowd/default.htm

Accessed March 27, 2007.

   2. Bernstein SL, Asplin BR. Emergency department crowding: old

problem, new solutions. Emerg Med Clin North Am. 2006;24:821-837.

Abstract

   3. Institute of Medicine, Board on Health Care Services.

Hospital-Based Emergency Care: At the Breaking Point. Washington, DC:

National Academies Press; 2006.

   4. Emergency Nurses Association. Emergency Nurses Association

Position Statement. Holding Patients in the Emergency Department. 2006.

Available at:

http://www.ena.org/about/position/PDFs/629CF897DF7D43F38CF40D5E20

      D5769D.pdf Accessed March 27, 2007.

   5. Schneider SM, Gallery ME, Schafermeyer R, Zwemer FL. Emergency

department crowding: a point in time. Ann Emerg Med. 2003;42:167-172.

Abstract

   6. Joint Commission on Accredition of Healthcare Organizations.

Comprehensive Accredition Manual for Hospitals. Oak Brook, Ill: JCAHO;

2006.

   7. National Institute for Occupational Safety and Health. Centers

for Disease Control and Prevention, Department of Health and Human

Services. Violence: Occupational Hazards in Hospitals. DHHS (NIOSH)

Publication No. 2002-101. April, 2002. Available at:

http://www.cdc.gov/niosh/2002-101.html#wheremay Accessed March 27,

2007.

   8. Emergency Nurses Association. Survey on Emergency Nurses

Perceptions of Their Profession. Desplaines, Ill: ENA; 2006.

   9. May DD, Grubbs LM. The extent, nature and precipitating factors

of nurse assault among three groups of registered nurses in a regional

medical center. J Emerg Nurs. 2002;28:11-17. Abstract

  10. Emergency Nurses Association. Emergency Nurses Association

Position Statement. Violence in the Emergency Care Setting. 2006.

Available at:

http://www.ena.org/about/position/PDFs/CFAC59534C2B4BFF8C23F1972

      A2E00FF.pdf Accessed March 27, 2007.

  11. Institute of Medicine. Report Brief. The Future of Emergency Care

in the United States Health System. June 2006. Available at:

http://www.iom.edu/Object.File/Master/35/014/Emergency%20Care.pdf

Accessed March 27, 2007.

 

Laura Stokowski, RN, MS, Staff Nurse, Inova Fairfax Hospital for

Children, Falls Church, Virginia; Editor, Medscape Ask the Experts

Advanced Practice Nurses