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Emergency Department Crowding, Part 1—Concept, Causes, and Moral Consequences
HEALTH POLICY AND CLINICAL PRACTICE/CONCEPTS
Emergency Department Crowding, Part 1—Concept, Causes, and Moral Consequences John C. Moskop, PhD David P. Sklar, MD Joel M. Geiderman, MD Raquel M. Schears, MD, MPH Kelly J. Bookman, MD
From the Department of Medical Humanities, The Brody School of Medicine, Bioethics Center, University Health Systems of Eastern Carolina, Greenville, NC (Moskop); the Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM (Sklar); the Ruth and Harry Roman Emergency Department, Department of Emergency Medicine, Cedars-Sinai Center for Health Care Ethics, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA (Geiderman); the Department of Emergency Medicine, Mayo Clinic College of Medicine/St. Mary’s Hospital, Rochester, MN (Schears); and the Department of Surgery, Division of Emergency Medicine, University of Colorado School of Medicine, Denver, CO (Bookman).
Crowding is an increasingly common occurrence in hospital-based emergency departments (EDs) across the globe. This 2-article series offers an ethical and policy analysis of ED crowding. Part 1 begins with a discussion of terms used to describe this situation and proposes that the term “crowding” be preferred to “overcrowding.” The article discusses definitions, measures, and causes of ED crowding and concludes that the inability to transfer emergency patients to inpatient beds and resultant boarding of admitted patients in the ED are among the root causes of ED crowding. Finally, the article identifies and describes a variety of adverse moral consequences of ED crowding, including increased risks of harm to patients, delays in providing needed care, compromised privacy and confidentiality, impaired communication, and diminished access to care. Part 2 of the series examines barriers to resolving the problem of ED crowding and strategies proposed to overcome those barriers. [Ann Emerg Med. 2009; 53:605-611.] 0196-0644/$-see front matter Copyright © 2008 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2008.09.019
SEE RELATED ARTICLE, P. 612. INTRODUCTION Hospital-based emergency departments (EDs) have evolved during the past 2 decades to provide not only acute emergency care but also safety net care for indigent patients, public health surveillance, disaster preparedness, observation and procedural care (eg, blood transfusions), occupational care, employee health, and, in many cases, primary health care.1 Despite these expanding services, ED resources, including the overall number of ED facilities, beds within those facilities, and funding, have not increased commensurately. Instead, the number of EDs in the United States, along with the total number of US hospitals and of inpatient beds in those hospitals, has decreased significantly during the past 2 decades.2,3 The result, according to Hospital-Based Emergency Care: At the Breaking Point, a 2006 report of the Institute of Medicine (IOM) Committee on the Future of Emergency Care in the United States Health System, is a national crisis of ED crowding.1 This 2-article series provides an ethical and policy analysis of the current crisis of ED crowding. Part 1 begins with a brief review of the concept and causes of ED crowding. We identify and describe multiple reasons why ED crowding constitutes a morally significant problem. In part 2 of the series, we describe Volume , . : May
a number of operational and financial barriers to alleviating the problem of crowding, along with operational strategies that have been suggested to overcome those barriers. Part 2 concludes with a review and evaluation of 2 recent proposals for action to address the crisis of ED crowding.
CONCEPT AND CAUSES The issue of ED crowding is not new. Early reports of crowding appeared in the emergency medicine literature almost 20 years ago,4,5 followed during the past decade by multiple studies of the incidence, causes, and consequences of crowding. Despite this long and growing attention to the problem of ED crowding, there remains a lack of consensus on the terminology used to refer to it, on an operational definition to identify it, and on a system or scale to measure it. Recent studies appear to be moving toward consensus on the root cause of ED crowding and on some significant consequences of this phenomenon. This section will be devoted to a brief review of issues of terminology, definitions, measures, and causes of crowding. Terminology What is the most appropriate term to refer to the situation in a “full” or “overloaded” ED? A survey of the expanding literature reveals that 2 terms, “crowding” and “overcrowding,” Annals of Emergency Medicine 605
Concept, Causes and Moral Consequences of Crowding are commonly used for this purpose, with most authors simply choosing one or the other of the 2 terms without explaining why they prefer it. The 2006 IOM report on hospital-based emergency care cited above uses both terms, apparently interchangeably, in its executive summary, but chapter 4 of the report, devoted to patient flow through the ED, refers only to “crowding.”1 Because there is no indication in the literature that these 2 terms are being used to refer to different states of affairs, the situation appears to be a terminologic distinction without a real difference, and one of these 2 terms should probably become the preferred term. The question remains, however, whether one of these 2 terms is in some way more accurate or more effective in representing the problem confronting EDs. The 2 terms are obviously similar. When used with respect to people, both terms suggest the presence of a large number of people relative to a given space. The term “overcrowding” suggests a more extreme situation and has a stronger negative connotation than “crowding,” and some commentators on the current ED crisis may prefer “overcrowding” for those very reasons. It would be misleading, however, to suggest that ED “crowding” is perfectly acceptable and only “overcrowding” is problematic; instead, we believe that ED “crowding,” as well as “overcrowding,” poses significant moral risks to patients. We have therefore chosen to use the term “crowding” in this article. It is also worth noting that a consensus may be emerging in favor of the term “crowding” to describe the situation now facing EDs. In 2 statements published in 1990, the American College of Emergency Physicians (ACEP) used the term “emergency department overcrowding,”6,7 but a 2006 ACEP policy statement is titled “Crowding.”8 Review of 2 leading emergency medicine journals (Annals of Emergency Medicine and Academic Emergency Medicine) reveals that, from January 2006 through January 2008, the term “crowding” appeared in 17 article titles and the term “overcrowding” in only 4 titles. For the reasons offered above, we propose “crowding” as the preferred term to describe the undesirable state of affairs that is the subject of this article. Definition Despite growing agreement on the extent and seriousness of the problem of ED crowding, debate continues about the most appropriate definition and measures for crowding. In its 2006 policy statement, ACEP asserts that “[c]rowding occurs when the identified need for emergency services exceeds available resources for patient care in the ED, hospital, or both.”8 This description suggests that crowding can be quantified as a relation between variables in 2 categories: needs for service and available resources. In 2003, Asplin et al9 proposed a conceptual model of ED crowding based on 3 interdependent components: input (the amount and types of care sought in the ED), throughput (the processes of care within the ED), and output (the movement of patients out of the ED to another care site). Another recent definition of ED crowding adds yet another variable, quality of care; Pines10 proposed that “an ED is 606 Annals of Emergency Medicine
Moskop et al crowded when inadequate resources to meet patient demands lead to a reduction in the quality of care.” One early attempt to measure the extent of ED crowding relied heavily on provider perceptions. In a 1999 survey of directors of US EDs, 91% of respondents reported that crowding is a problem, and 39% reported that their EDs are crowded every day.11 Later studies have proposed at least 5 different scoring systems using empirical variables to determine the existence and extent of ED crowding.12-16 Comparative evaluations of these scoring systems are beginning to appear, but none of the current models has yet demonstrated clear superiority over the others in identifying or predicting ED crowding.17,18 The lack of a consensus definition and measure for ED crowding makes very clear the need for additional analysis and research in this area. Pines10 describes the situation in graphic terms: “ED crowding is the elephant standing in the room; it is just very difficult to describe how heavy he is, how bad he smells, and just when the floor might give. Objective measures will move us one step closer to the ever-elusive operational definition for ED crowding.” If ED crowding is indeed a crisis of indefinite but elephantine proportions, it will also be of value to identify the moral dimensions of this crisis and the strategies available to defuse it. Causes Multiple factors are likely contributors to the growing crisis of ED crowding. National statistics during the past 15 years or more reveal a continuing strong growth in demand for ED care, coupled with a significant decrease in the number of health care facilities. From 1995 to 2005, annual ED visits in the United States increased by 20% (from 96.5 million to 115.3 million per year), and the ED utilization rate increased by 7%, from 36.9 to 39.6 ED visits per 100 persons.2 Despite the increase in ED visits, during this same decade the number of hospital EDs decreased by 381, the number of US hospitals decreased by 535, and the number of hospital beds shrank by 134,000.2,3 Many of these health care facility closures are likely due to financial pressures imposed by cuts in private and public insurance reimbursement and by treatment requirements imposed by the federal Emergency Medical Treatment and Active Labor Act (EMTALA), an unfunded mandate.19 Annual increases in ED visits in the United States are likely the result of US population increases (because of greater longevity and immigration), growth in the number of uninsured and underinsured persons, and the greater use of technologies available only at hospitals.20 In investigating the causes of crowding, researchers initially focused on input factors such as use of the ED for nonemergency complaints.4,21 More recent research, however, strongly suggests that these input factors are not the root cause of the problem.20,22-26 In a 2001 commentary, McCabe27 summarized the results of this research as follows: “It should be noted that one of the ‘whipping boys’ of the 1980s for ED overcrowding was the ‘unnecessary ED patient visit.’ It was thought that patients arriving in the ED with simple complaints Volume , . : May
Moskop et al (eg, ankle sprain, cold, medication prescription, refill, etc) were clogging up the system and were the cause of ED overcrowding. This was not true then and it is not true now. ED overcrowding occurs primarily when sick patients, evaluated by the emergency physician and admitted to the hospital, have no place to go and remain in the ED. It is mainly a symptom of an overcrowded hospital, not the result of ‘inappropriate’ ED use.”27 Additional studies published since 2001 confirm McCabe’s27 conclusion about the root cause of ED crowding. A recent study of 4.2 million visits to 110 EDs, for example, concluded that the number of patients with minor illnesses and injuries in these EDs had a negligible effect on waiting times for care of other, more acutely ill, ED patients.24 In 2 other recent studies, investigators have shown that overall hospital occupancy rates are strongly correlated with the length of stay of patients in the ED.25,26 In summary, current research on ED crowding strongly suggests that discouraging the use of the ED for nonemergency issues will not solve the problem. Rather, output issues, especially the inability to transfer emergency patients to inpatient beds and the resultant “boarding” of admitted patients in the ED for long periods, are most commonly associated with ED crowding.
MORAL CONSEQUENCES ED crowding poses obvious operational and logistic problems for hospitals, but it also raises serious ethical concerns.28,29 Crowding has a variety of undesirable consequences, including increased patient waiting times, decreased ability to protect patient privacy and confidentiality, impaired evaluation and treatment, and difficulties in delivering person-centered care. These consequences can be understood not just as undesirable or unfortunate but also as violations of widely held, fundamental moral norms. One well-known theoretical approach to bioethics holds that 4 clusters of fundamental moral principles, namely, nonmaleficence, beneficence, respect for autonomy, and justice, provide a useful framework for addressing ethical issues in health care.30 In this section, we will argue that ED crowding frequently interferes with the ability of emergency physicians to honor these fundamental principles. Along with leading proponents of this principles-based approach, we acknowledge that these principles are not absolute; that is, they can be justifiably overridden in some circumstances by other moral norms.30 Thus, an emergency physician working in a crowded ED may have no choice but to compromise a patient’s confidentiality or defer a patient’s urgent plea for assistance. However, when a circumstance such as ED crowding makes it increasingly difficult or even impossible for health care professionals to respect basic moral norms, we believe that it is essential to address that circumstance to reduce the likelihood of conflict between these moral norms and to enable professionals to satisfy all of the reasonable moral expectations of their patients. We turn now to a consideration of each principle in turn. Volume , . : May
Concept, Causes and Moral Consequences of Crowding (1) Primum non nocere, “Above all, do no harm,” is a central principle of medical ethics with origins in antiquity.31 Contemporary accounts of this principle of nonmaleficence interpret it to prohibit physicians from inflicting evil or harm and from exposing patients to unnecessary risks of harm.30 Although we are confident that emergency physicians avoid making any deliberate decisions to inflict harm on a patient, circumstantial evidence suggests that ED crowding does pose serious unintended risks of harm to ED patients. For example, in a recent study of sentinel events, that is, “unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof,” The Joint Commission (formerly Joint Commission on Accreditation of Healthcare Organizations) reported that of 55 events associated with delays in care, 29 occurred in EDs.32 Crowding was noted to contribute to 31% of sentinel events in the ED. Two recent Australian studies found a significant association between ED crowding and increased inpatient mortality.33,34 Crowding increases the risk of harmful medical errors in a variety of ways.35 In a crowded ED, errors may occur as a result of hurried treatment decisions with limited information, of delayed or poorly organized transfer of information from one clinician to another, or of failure to reexamine a patient or to reevaluate a previous physician’s provisional diagnosis or treatment plan. (2) Nonmaleficence is generally understood as a negative duty, that is, a duty to refrain from inflicting harm. In addition to this negative duty, physicians and other health care professionals embrace a positive duty to act for the benefit of the sick and injured. This positive duty is grounded in the principle of beneficence. Physicians seek to benefit their patients by preventing harmful outcomes, alleviating or removing existing harms, and promoting good outcomes.30 In the ED, physicians mitigate harm to patients by promptly providing definitive treatment to correct life-threatening illness or injury. Numerous emergency conditions, including myocardial infarction, stroke, trauma, meningitis, and pneumonia, have been shown to have time-sensitive outcomes. Multiple studies associate ED crowding with delays in access to definitive therapy for emergency conditions, thereby increasing the risk of poorer outcomes.36-40 By delaying patient access to assessment and treatment, crowding also forces patients to endure existing harms, including pain and anxiety, for prolonged periods.41 In all of these ways, crowding impedes clinicians’ efforts to carry out their duties of beneficence. There are clear limits to the benefits patients can claim and health care professionals have a duty to provide, both in the ED and elsewhere in the health care system. Our concern, however, is that ED crowding has become serious enough to threaten the ability of emergency physicians to provide the central benefits of emergency care, especially prompt and effective treatment for life-threatening illnesses and injuries. (3) In addition to interfering with the provision of beneficial emergency care, crowding may prevent emergency physicians from honoring a third foundational principle of bioethics, the Annals of Emergency Medicine 607
Concept, Causes and Moral Consequences of Crowding principle of respect for autonomy.30 This principle grounds patient rights to informed consent and refusal of treatment. Patients also have autonomy-based interests in choosing where and when they will receive health care. Patient choice of care is in fact limited by personal and system resources, but enabling patients to choose care that is effective and convenient remains a legitimate moral goal. ED crowding interferes with the satisfaction of that goal when it triggers ambulance diversion and long waiting times for ED care and for hospital admission. According to a recent study, more than half a million ambulances were diverted in 2003, an average of 1 per minute.42 Ambulance diversion to other hospitals often thwarts patients’ strong preference to receive care in the hospital in which their physicians and medical records are located. Diversion also increases transportation time for each patient. Longer transportation times may increase ambulance response time to subsequent patients, thereby delaying those patients’ access to out-of-hospital and ED care for their emergency medical conditions.43 Thus, ED crowding resulting in ambulance diversion can compromise both the autonomy and well-being of patients. To exercise freedom of choice and action, persons must have substantial control over their physical environment and over private information about themselves.44 Therefore, the principle of autonomy also grounds patient rights to privacy and confidentiality. ED crowding forces clinicians to care for patients in spaces in which they are in close proximity to one another, to ED visitors, and to others in the semiopen environment of the ED, including hallways, waiting areas, and other shared spaces. In these settings, clinicians may be unable to protect the physical privacy and modesty of their patients. The exposure to others of intimate body parts and invasive treatments may evoke feelings of violation, acute embarrassment, shame, or resentment. An alternative approach that protects privacy and confidentiality would be to keep each patient in the ED waiting area until a suitable treatment space becomes available. This approach, however, delays patient access to needed treatment and, as noted above, increases the risk of poorer patient outcomes. Lack of physical privacy in crowded ED treatment settings also inhibits open communication between physicians and patients about sensitive medical conditions and treatment options. Providers and patients confront a dilemma of limiting disclosure of information that might be embarrassing, or allowing others to overhear that sensitive or personal information. If patients choose not to disclose sensitive information about their medical history or condition, the ability of their physicians to diagnose their condition accurately and treat that condition effectively may be compromised. If physicians choose not to reveal important but sensitive information about treatment options, patients will be required to make treatment decisions without relevant information that could have been shared in a more private setting, and without 608 Annals of Emergency Medicine
Moskop et al the opportunity to fully discuss their concerns with their provider. Finally, if patients and clinicians do choose to discuss personal information about a particular condition and its treatment despite the lack of physical privacy in a crowded ED, that information will likely be overheard by others, and the confidentiality of the information will be compromised. Allowing an environment to exist in which such critical information exchange is unprotected may erode patient trust and also violate federal confidentiality regulations mandated under the Health Insurance Portability and Accountability Act.45 (4) The fourth cluster of principles of biomedical ethics addresses issues of justice, especially the just distribution of health care resources. With significant increases in both the effectiveness and the cost of health care during the past 50 years, issues of distributive justice in health care have become more pressing and more complex. Governments, institutions, and providers around the world struggle to decide who should receive the substantial benefits of access to various types of health care and who should bear the substantial burdens of paying for that care. In the United States, these decisions are complicated by a lack of societal consensus on a guiding theory of distributive justice. Rather, a variety of distinct principles of distributive justice, often with different conclusions about the proper distribution of benefits and burdens, compete for influence and support. ED crowding is the result, foreseen or unforeseen, of a number of decisions about access to health care and distribution of health care resources. As noted above, these decisions have a variety of consequences for patients who seek care in crowded EDs. Because these consequences are the result of previous allocation decisions, we can evaluate the justice of those allocation decisions. Two widely held principles of distributive justice in health care can be invoked to evaluate a system of health care resource allocation that permits frequent and widespread crowding of EDs. The first of these principles asserts that, when health care resources are scarce, priority for treatment should be given to patients whose needs are greatest. This principle underlies a variety of triage systems developed to allocate scarce medical resources.46,47 In the US health care system today, inpatient hospital beds can be viewed as a scarce resource needed by both ED patients awaiting hospital admission and current inpatients who are occupying those beds. The first 24 hours have been identified as the most resource-intensive hours of a hospitalization; thus, many patients who present to the ED with conditions requiring hospital admission have their greatest need for specialized inpatient services such as advanced diagnostic tests, surgery, or intensive care in those initial hours after they present. If these acutely ill or injured patients are boarded for long periods in a crowded ED, they are at high risk for delays in treatment and for reduced attention, as emergency physicians and staff struggle to care for new patients as they arrive. In Volume , . : May
Moskop et al contrast, hospital inpatients near the end of their hospitalization, who are often awaiting nursing home placement or social work assistance in obtaining important medical equipment, probably have the lowest need for hospital care. Despite their reduced need for care, however, these patients continue to occupy an inpatient bed. Thus, the principle of access to health care based on urgency or magnitude of need appears to dictate that inpatient care be reallocated from current inpatients nearing discharge to ED patients awaiting hospital admission. Unfortunately, a limited number of long-term care facilities (partly as a result of inadequate compensation),48 combined with the inability or unwillingness of family members to care for the patient in a home setting, leaves the hospital as the provider of last resort for medically stable patients recuperating from illnesses that initially required hospitalization. Policymakers, politicians, and others in society will need to confront this issue as the elderly comprise an ever larger percentage of our population. A second widely held principle of distributive justice in health care asserts that access to care should be based on medical criteria and not on social or economic criteria such as ethnicity, religion, sex, age, disability, sexual orientation, income level, or insurance status. Partial affirmation of this principle can be found in the federal EMTALA requirement that EDs provide a screening examination and stabilizing treatment for all patients with emergency medical conditions.19 Patients admitted to the hospital through the ED may differ significantly in several of these social and economic criteria from patients admitted through other mechanisms, eg, direct admissions, scheduled surgeries, planned transfers. Thus, de facto, ED patients may be discriminated against if they are, as a matter of policy or routine practice, assigned a low priority for access to inpatient beds. As noted above, ED crowding is one consequence of decisions about the distribution of health care resources, and thus it raises questions of distributive justice. These questions arise on multiple levels. At the societal level, for example, national, state, and local governmental officials decide who will be guaranteed access to what kinds of health care and what public resources will be invested in the construction and staffing of hospitals and other health care facilities. At the institutional level, hospitals formulate policies and procedures for the admission and discharge of patients, open new hospital units to relieve crowding or to provide new patient services, and close other units where demand or reimbursement is insufficient. At the individual level, hospital admissions officers, in consultation with emergency physicians and other providers, determine which of several waiting patients will be assigned the next available inpatient bed. If hospital EDs in the United States have a moral and legal mandate to provide quality emergency care to all who need it, it is important that emergency physicians and nurses make governmental and institutional leaders aware of the significant problem of ED crowding and that they participate in efforts to address this problem. Several such efforts are described in part 2 of this article. Volume , . : May
Concept, Causes and Moral Consequences of Crowding In addition to its negative effects on patients, the experience of observing frequent delays in care and of evaluating and treating patients in areas without privacy has serious short- and long-term consequences for providers, including decreased job satisfaction, frustration, anger, depression, and ultimately burnout.49 These are classic reactions to ethical dilemmas that resist solution. Emergency physicians expect occasional situations in which resources are not adequate for the needs of patients, and they are prepared to manage these situations as effectively as possible. Health care professionals may not be able to sustain a constructive response, however, when ED crowding persists despite their ongoing best efforts to alleviate this problem. Because the concept, causes, and consequences of ED crowding are not fully understood, a robust research agenda on this topic remains to be pursued.50 Enough is understood, however, for the IOM to conclude that ED crowding now constitutes a national crisis. In part 1 of this 2-article series, we have emphasized the moral significance of the crisis of ED crowding. Part 2 of the series will identify and analyze barriers to resolving this crisis and various strategies proposed to overcome those barriers. For the ACEP Ethics Committee. Supervising editor: Robert K. Knopp, MD Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Earn CME Credit: Continuing Medical Education is available for this article at: www.ACEP-EMedHome.com. Publication dates: Received for publication May 21, 2008. Revision received September 10, 2008. Accepted for publication September 22, 2008. Available online November 11, 2008. Reprints not available from the authors. Address for correspondence: John C. Moskop, PhD, Department of Medical Humanities, The Brody School of Medicine, 600 Moye Boulevard, Greenville, NC 27834; 252744-2617, Fax 252-744-2319; Email [email protected].
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Concept, Causes and Moral Consequences of Crowding 3. AHA Hospital Statistics. Chicago, IL: Health Forum; 2008. 4. Gallagher EJ, Lynn SG. The etiology of medical gridlock: causes of emergency department overcrowding in New York City. J Emerg Med. 1990;8:785-790. 5. Andrulis DP, Kellermann A, Hintz EA, et al. Emergency departments and crowding in United States teaching hospitals. Ann Emerg Med. 1991;20:980-986. 6. American College of Emergency Physicians. Hospital and emergency department overcrowding. Ann Emerg Med. 1990;19: 336. 7. Measures to deal with emergency department overcrowding. American College of Emergency Physicians. Ann Emerg Med. 1990;20:944-945. 8. American College of Emergency Physicians. Crowding (policy statement). Approved January 2006. Available at: http://www.acep.org/practres.aspx?id⫽29156. Accessed February 15, 2008. 9. Asplin BR, Magid DJ, Rhodes KV, et al. A conceptual model of emergency department crowding. Ann Emerg Med. 2003;42:173180. 10. Pines JM. Moving closer to an operational definition for ED crowding [letter]. Acad Emerg Med. 2007;14:382-383. 11. Derlet RW, Richards JR, Kravitz RL. Frequent overcrowding in US emergency departments. Acad Emerg Med. 2001;8:151-155. 12. Reeder TJ, Garrison HG. When the safety net is unsafe: real time assessment of the overcrowded emergency department. Acad Emerg Med. 2001;8:1070-1074. 13. Bernstein SL, Verghese V, Leung W, et al. Development and validation of a new index to measure emergency department crowding. Acad Emerg Med. 2003;10:938-942. 14. Weiss SJ, Derlet R, Arndahl J, et al. Estimating the degree of emergency department overcrowding in academic medical centers: results of the National ED Overcrowding Study (NEDOCS). Acad Emerg Med. 2004;11:38-50. 15. Asplin BR, Rhodes KV, Flottemesch TJ, et al. Is this emergency department crowded? a multicenter derivation and evaluation of an emergency department crowding scale (EDCS). Acad Emerg Med. 2004;11:484-485. 16. McCarthy ML, Aronsky D, Jones ID, et al. The emergency department occupancy rate: a simple measure of emergency department crowding? Ann Emerg Med. 2008;51:15-24. 17. Jones SS, Allen TL, Flottemesch TJ, et al. An independent evaluation of four quantitative emergency department crowding scales. Acad Emerg Med. 2006;13:1204-1211. 18. Hoot NR, Zhou C, Jones I, et al. Measuring and forecasting emergency department crowding in real time. Ann Emerg Med. 2007;49:747-755. 19. Emergency Medical Treatment and Active Labor Act. 42 USC 1395dd et seq. 20. Olshaker JS, Rathlev NK. Emergency department overcrowding and ambulance diversion: the impact and potential solutions of extended boarding of admitted patients in the emergency department. J Emerg Med. 2006;30:351-356. 21. United States General Accounting Office. Emergency departments: unevenly affected by growth and change in patient use. Report to the Chairman, Subcommittee on Health for Families and the Uninsured, Committee on Finance, US Senate, January 1993. Available at: http://161.203.16.4/d36t11/ 148331.pdf. Accessed February 15, 2008. 22. Trzeciak S, Rivers E. Emergency department overcrowding in the United States: an emerging threat to patient safety and public health. Emerg Med J. 2003;20:402-405. 23. Espinosa G, Miro O, Sanchez M, et al. Effects of external and internal factors on emergency department overcrowding [letter]. Ann Emerg Med. 2002;39:693-695.
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Moskop et al 44. Moskop JC, Marco CA, Larkin GL, et al. From Hippocrates to HIPAA: privacy and confidentiality in emergency medicine—part I: conceptual and legal foundations. Ann Emerg Med. 2005;45:53-59. 45. US Department of Health and Human Services, Office for Civil Rights. Summary of the HIPAA privacy rule. Available at: http:// www.hhs.gov/ocr/privacysummary.pdf. Accessed February 15, 2008. 46. Iserson KV, Moskop JC. Triage in medicine, part I: concept, history, and types. Ann Emerg Med. 2007;49:275-281.
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Concept, Causes and Moral Consequences of Crowding 47. Moskop JC, Iserson KV. Triage in medicine, part II: underlying values and principles. Ann Emerg Med. 2007;49:282-287. 48. The coming crisis of long-term care. Lancet. 2003;361:1755. 49. Rondeau KV, Francescutti LH. Emergency department overcrowding: the impact of resource scarcity on physician job satisfaction. J Healthc Manag. 2005;50:327-340. 50. Bernstein SL, Asplin BR. Emergency department crowding: old problem, new solutions. Emerg Med Clin North Am. 2006;24:821837.
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Emergency Department Crowding, Part 1—Concept, Causes, and Moral Consequences John C. Moskop, PhD David P. Sklar, MD Joel M. Geiderman, MD Raquel M. Schears, MD, MPH Kelly J. Bookman, MD
From the Department of Medical Humanities, The Brody School of Medicine, Bioethics Center, University Health Systems of Eastern Carolina, Greenville, NC (Moskop); the Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM (Sklar); the Ruth and Harry Roman Emergency Department, Department of Emergency Medicine, Cedars-Sinai Center for Health Care Ethics, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA (Geiderman); the Department of Emergency Medicine, Mayo Clinic College of Medicine/St. Mary’s Hospital, Rochester, MN (Schears); and the Department of Surgery, Division of Emergency Medicine, University of Colorado School of Medicine, Denver, CO (Bookman).
Crowding is an increasingly common occurrence in hospital-based emergency departments (EDs) across the globe. This 2-article series offers an ethical and policy analysis of ED crowding. Part 1 begins with a discussion of terms used to describe this situation and proposes that the term “crowding” be preferred to “overcrowding.” The article discusses definitions, measures, and causes of ED crowding and concludes that the inability to transfer emergency patients to inpatient beds and resultant boarding of admitted patients in the ED are among the root causes of ED crowding. Finally, the article identifies and describes a variety of adverse moral consequences of ED crowding, including increased risks of harm to patients, delays in providing needed care, compromised privacy and confidentiality, impaired communication, and diminished access to care. Part 2 of the series examines barriers to resolving the problem of ED crowding and strategies proposed to overcome those barriers. [Ann Emerg Med. 2009; 53:605-611.] 0196-0644/$-see front matter Copyright © 2008 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2008.09.019
SEE RELATED ARTICLE, P. 612. INTRODUCTION Hospital-based emergency departments (EDs) have evolved during the past 2 decades to provide not only acute emergency care but also safety net care for indigent patients, public health surveillance, disaster preparedness, observation and procedural care (eg, blood transfusions), occupational care, employee health, and, in many cases, primary health care.1 Despite these expanding services, ED resources, including the overall number of ED facilities, beds within those facilities, and funding, have not increased commensurately. Instead, the number of EDs in the United States, along with the total number of US hospitals and of inpatient beds in those hospitals, has decreased significantly during the past 2 decades.2,3 The result, according to Hospital-Based Emergency Care: At the Breaking Point, a 2006 report of the Institute of Medicine (IOM) Committee on the Future of Emergency Care in the United States Health System, is a national crisis of ED crowding.1 This 2-article series provides an ethical and policy analysis of the current crisis of ED crowding. Part 1 begins with a brief review of the concept and causes of ED crowding. We identify and describe multiple reasons why ED crowding constitutes a morally significant problem. In part 2 of the series, we describe Volume , . : May
a number of operational and financial barriers to alleviating the problem of crowding, along with operational strategies that have been suggested to overcome those barriers. Part 2 concludes with a review and evaluation of 2 recent proposals for action to address the crisis of ED crowding.
CONCEPT AND CAUSES The issue of ED crowding is not new. Early reports of crowding appeared in the emergency medicine literature almost 20 years ago,4,5 followed during the past decade by multiple studies of the incidence, causes, and consequences of crowding. Despite this long and growing attention to the problem of ED crowding, there remains a lack of consensus on the terminology used to refer to it, on an operational definition to identify it, and on a system or scale to measure it. Recent studies appear to be moving toward consensus on the root cause of ED crowding and on some significant consequences of this phenomenon. This section will be devoted to a brief review of issues of terminology, definitions, measures, and causes of crowding. Terminology What is the most appropriate term to refer to the situation in a “full” or “overloaded” ED? A survey of the expanding literature reveals that 2 terms, “crowding” and “overcrowding,” Annals of Emergency Medicine 605
Concept, Causes and Moral Consequences of Crowding are commonly used for this purpose, with most authors simply choosing one or the other of the 2 terms without explaining why they prefer it. The 2006 IOM report on hospital-based emergency care cited above uses both terms, apparently interchangeably, in its executive summary, but chapter 4 of the report, devoted to patient flow through the ED, refers only to “crowding.”1 Because there is no indication in the literature that these 2 terms are being used to refer to different states of affairs, the situation appears to be a terminologic distinction without a real difference, and one of these 2 terms should probably become the preferred term. The question remains, however, whether one of these 2 terms is in some way more accurate or more effective in representing the problem confronting EDs. The 2 terms are obviously similar. When used with respect to people, both terms suggest the presence of a large number of people relative to a given space. The term “overcrowding” suggests a more extreme situation and has a stronger negative connotation than “crowding,” and some commentators on the current ED crisis may prefer “overcrowding” for those very reasons. It would be misleading, however, to suggest that ED “crowding” is perfectly acceptable and only “overcrowding” is problematic; instead, we believe that ED “crowding,” as well as “overcrowding,” poses significant moral risks to patients. We have therefore chosen to use the term “crowding” in this article. It is also worth noting that a consensus may be emerging in favor of the term “crowding” to describe the situation now facing EDs. In 2 statements published in 1990, the American College of Emergency Physicians (ACEP) used the term “emergency department overcrowding,”6,7 but a 2006 ACEP policy statement is titled “Crowding.”8 Review of 2 leading emergency medicine journals (Annals of Emergency Medicine and Academic Emergency Medicine) reveals that, from January 2006 through January 2008, the term “crowding” appeared in 17 article titles and the term “overcrowding” in only 4 titles. For the reasons offered above, we propose “crowding” as the preferred term to describe the undesirable state of affairs that is the subject of this article. Definition Despite growing agreement on the extent and seriousness of the problem of ED crowding, debate continues about the most appropriate definition and measures for crowding. In its 2006 policy statement, ACEP asserts that “[c]rowding occurs when the identified need for emergency services exceeds available resources for patient care in the ED, hospital, or both.”8 This description suggests that crowding can be quantified as a relation between variables in 2 categories: needs for service and available resources. In 2003, Asplin et al9 proposed a conceptual model of ED crowding based on 3 interdependent components: input (the amount and types of care sought in the ED), throughput (the processes of care within the ED), and output (the movement of patients out of the ED to another care site). Another recent definition of ED crowding adds yet another variable, quality of care; Pines10 proposed that “an ED is 606 Annals of Emergency Medicine
Moskop et al crowded when inadequate resources to meet patient demands lead to a reduction in the quality of care.” One early attempt to measure the extent of ED crowding relied heavily on provider perceptions. In a 1999 survey of directors of US EDs, 91% of respondents reported that crowding is a problem, and 39% reported that their EDs are crowded every day.11 Later studies have proposed at least 5 different scoring systems using empirical variables to determine the existence and extent of ED crowding.12-16 Comparative evaluations of these scoring systems are beginning to appear, but none of the current models has yet demonstrated clear superiority over the others in identifying or predicting ED crowding.17,18 The lack of a consensus definition and measure for ED crowding makes very clear the need for additional analysis and research in this area. Pines10 describes the situation in graphic terms: “ED crowding is the elephant standing in the room; it is just very difficult to describe how heavy he is, how bad he smells, and just when the floor might give. Objective measures will move us one step closer to the ever-elusive operational definition for ED crowding.” If ED crowding is indeed a crisis of indefinite but elephantine proportions, it will also be of value to identify the moral dimensions of this crisis and the strategies available to defuse it. Causes Multiple factors are likely contributors to the growing crisis of ED crowding. National statistics during the past 15 years or more reveal a continuing strong growth in demand for ED care, coupled with a significant decrease in the number of health care facilities. From 1995 to 2005, annual ED visits in the United States increased by 20% (from 96.5 million to 115.3 million per year), and the ED utilization rate increased by 7%, from 36.9 to 39.6 ED visits per 100 persons.2 Despite the increase in ED visits, during this same decade the number of hospital EDs decreased by 381, the number of US hospitals decreased by 535, and the number of hospital beds shrank by 134,000.2,3 Many of these health care facility closures are likely due to financial pressures imposed by cuts in private and public insurance reimbursement and by treatment requirements imposed by the federal Emergency Medical Treatment and Active Labor Act (EMTALA), an unfunded mandate.19 Annual increases in ED visits in the United States are likely the result of US population increases (because of greater longevity and immigration), growth in the number of uninsured and underinsured persons, and the greater use of technologies available only at hospitals.20 In investigating the causes of crowding, researchers initially focused on input factors such as use of the ED for nonemergency complaints.4,21 More recent research, however, strongly suggests that these input factors are not the root cause of the problem.20,22-26 In a 2001 commentary, McCabe27 summarized the results of this research as follows: “It should be noted that one of the ‘whipping boys’ of the 1980s for ED overcrowding was the ‘unnecessary ED patient visit.’ It was thought that patients arriving in the ED with simple complaints Volume , . : May
Moskop et al (eg, ankle sprain, cold, medication prescription, refill, etc) were clogging up the system and were the cause of ED overcrowding. This was not true then and it is not true now. ED overcrowding occurs primarily when sick patients, evaluated by the emergency physician and admitted to the hospital, have no place to go and remain in the ED. It is mainly a symptom of an overcrowded hospital, not the result of ‘inappropriate’ ED use.”27 Additional studies published since 2001 confirm McCabe’s27 conclusion about the root cause of ED crowding. A recent study of 4.2 million visits to 110 EDs, for example, concluded that the number of patients with minor illnesses and injuries in these EDs had a negligible effect on waiting times for care of other, more acutely ill, ED patients.24 In 2 other recent studies, investigators have shown that overall hospital occupancy rates are strongly correlated with the length of stay of patients in the ED.25,26 In summary, current research on ED crowding strongly suggests that discouraging the use of the ED for nonemergency issues will not solve the problem. Rather, output issues, especially the inability to transfer emergency patients to inpatient beds and the resultant “boarding” of admitted patients in the ED for long periods, are most commonly associated with ED crowding.
MORAL CONSEQUENCES ED crowding poses obvious operational and logistic problems for hospitals, but it also raises serious ethical concerns.28,29 Crowding has a variety of undesirable consequences, including increased patient waiting times, decreased ability to protect patient privacy and confidentiality, impaired evaluation and treatment, and difficulties in delivering person-centered care. These consequences can be understood not just as undesirable or unfortunate but also as violations of widely held, fundamental moral norms. One well-known theoretical approach to bioethics holds that 4 clusters of fundamental moral principles, namely, nonmaleficence, beneficence, respect for autonomy, and justice, provide a useful framework for addressing ethical issues in health care.30 In this section, we will argue that ED crowding frequently interferes with the ability of emergency physicians to honor these fundamental principles. Along with leading proponents of this principles-based approach, we acknowledge that these principles are not absolute; that is, they can be justifiably overridden in some circumstances by other moral norms.30 Thus, an emergency physician working in a crowded ED may have no choice but to compromise a patient’s confidentiality or defer a patient’s urgent plea for assistance. However, when a circumstance such as ED crowding makes it increasingly difficult or even impossible for health care professionals to respect basic moral norms, we believe that it is essential to address that circumstance to reduce the likelihood of conflict between these moral norms and to enable professionals to satisfy all of the reasonable moral expectations of their patients. We turn now to a consideration of each principle in turn. Volume , . : May
Concept, Causes and Moral Consequences of Crowding (1) Primum non nocere, “Above all, do no harm,” is a central principle of medical ethics with origins in antiquity.31 Contemporary accounts of this principle of nonmaleficence interpret it to prohibit physicians from inflicting evil or harm and from exposing patients to unnecessary risks of harm.30 Although we are confident that emergency physicians avoid making any deliberate decisions to inflict harm on a patient, circumstantial evidence suggests that ED crowding does pose serious unintended risks of harm to ED patients. For example, in a recent study of sentinel events, that is, “unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof,” The Joint Commission (formerly Joint Commission on Accreditation of Healthcare Organizations) reported that of 55 events associated with delays in care, 29 occurred in EDs.32 Crowding was noted to contribute to 31% of sentinel events in the ED. Two recent Australian studies found a significant association between ED crowding and increased inpatient mortality.33,34 Crowding increases the risk of harmful medical errors in a variety of ways.35 In a crowded ED, errors may occur as a result of hurried treatment decisions with limited information, of delayed or poorly organized transfer of information from one clinician to another, or of failure to reexamine a patient or to reevaluate a previous physician’s provisional diagnosis or treatment plan. (2) Nonmaleficence is generally understood as a negative duty, that is, a duty to refrain from inflicting harm. In addition to this negative duty, physicians and other health care professionals embrace a positive duty to act for the benefit of the sick and injured. This positive duty is grounded in the principle of beneficence. Physicians seek to benefit their patients by preventing harmful outcomes, alleviating or removing existing harms, and promoting good outcomes.30 In the ED, physicians mitigate harm to patients by promptly providing definitive treatment to correct life-threatening illness or injury. Numerous emergency conditions, including myocardial infarction, stroke, trauma, meningitis, and pneumonia, have been shown to have time-sensitive outcomes. Multiple studies associate ED crowding with delays in access to definitive therapy for emergency conditions, thereby increasing the risk of poorer outcomes.36-40 By delaying patient access to assessment and treatment, crowding also forces patients to endure existing harms, including pain and anxiety, for prolonged periods.41 In all of these ways, crowding impedes clinicians’ efforts to carry out their duties of beneficence. There are clear limits to the benefits patients can claim and health care professionals have a duty to provide, both in the ED and elsewhere in the health care system. Our concern, however, is that ED crowding has become serious enough to threaten the ability of emergency physicians to provide the central benefits of emergency care, especially prompt and effective treatment for life-threatening illnesses and injuries. (3) In addition to interfering with the provision of beneficial emergency care, crowding may prevent emergency physicians from honoring a third foundational principle of bioethics, the Annals of Emergency Medicine 607
Concept, Causes and Moral Consequences of Crowding principle of respect for autonomy.30 This principle grounds patient rights to informed consent and refusal of treatment. Patients also have autonomy-based interests in choosing where and when they will receive health care. Patient choice of care is in fact limited by personal and system resources, but enabling patients to choose care that is effective and convenient remains a legitimate moral goal. ED crowding interferes with the satisfaction of that goal when it triggers ambulance diversion and long waiting times for ED care and for hospital admission. According to a recent study, more than half a million ambulances were diverted in 2003, an average of 1 per minute.42 Ambulance diversion to other hospitals often thwarts patients’ strong preference to receive care in the hospital in which their physicians and medical records are located. Diversion also increases transportation time for each patient. Longer transportation times may increase ambulance response time to subsequent patients, thereby delaying those patients’ access to out-of-hospital and ED care for their emergency medical conditions.43 Thus, ED crowding resulting in ambulance diversion can compromise both the autonomy and well-being of patients. To exercise freedom of choice and action, persons must have substantial control over their physical environment and over private information about themselves.44 Therefore, the principle of autonomy also grounds patient rights to privacy and confidentiality. ED crowding forces clinicians to care for patients in spaces in which they are in close proximity to one another, to ED visitors, and to others in the semiopen environment of the ED, including hallways, waiting areas, and other shared spaces. In these settings, clinicians may be unable to protect the physical privacy and modesty of their patients. The exposure to others of intimate body parts and invasive treatments may evoke feelings of violation, acute embarrassment, shame, or resentment. An alternative approach that protects privacy and confidentiality would be to keep each patient in the ED waiting area until a suitable treatment space becomes available. This approach, however, delays patient access to needed treatment and, as noted above, increases the risk of poorer patient outcomes. Lack of physical privacy in crowded ED treatment settings also inhibits open communication between physicians and patients about sensitive medical conditions and treatment options. Providers and patients confront a dilemma of limiting disclosure of information that might be embarrassing, or allowing others to overhear that sensitive or personal information. If patients choose not to disclose sensitive information about their medical history or condition, the ability of their physicians to diagnose their condition accurately and treat that condition effectively may be compromised. If physicians choose not to reveal important but sensitive information about treatment options, patients will be required to make treatment decisions without relevant information that could have been shared in a more private setting, and without 608 Annals of Emergency Medicine
Moskop et al the opportunity to fully discuss their concerns with their provider. Finally, if patients and clinicians do choose to discuss personal information about a particular condition and its treatment despite the lack of physical privacy in a crowded ED, that information will likely be overheard by others, and the confidentiality of the information will be compromised. Allowing an environment to exist in which such critical information exchange is unprotected may erode patient trust and also violate federal confidentiality regulations mandated under the Health Insurance Portability and Accountability Act.45 (4) The fourth cluster of principles of biomedical ethics addresses issues of justice, especially the just distribution of health care resources. With significant increases in both the effectiveness and the cost of health care during the past 50 years, issues of distributive justice in health care have become more pressing and more complex. Governments, institutions, and providers around the world struggle to decide who should receive the substantial benefits of access to various types of health care and who should bear the substantial burdens of paying for that care. In the United States, these decisions are complicated by a lack of societal consensus on a guiding theory of distributive justice. Rather, a variety of distinct principles of distributive justice, often with different conclusions about the proper distribution of benefits and burdens, compete for influence and support. ED crowding is the result, foreseen or unforeseen, of a number of decisions about access to health care and distribution of health care resources. As noted above, these decisions have a variety of consequences for patients who seek care in crowded EDs. Because these consequences are the result of previous allocation decisions, we can evaluate the justice of those allocation decisions. Two widely held principles of distributive justice in health care can be invoked to evaluate a system of health care resource allocation that permits frequent and widespread crowding of EDs. The first of these principles asserts that, when health care resources are scarce, priority for treatment should be given to patients whose needs are greatest. This principle underlies a variety of triage systems developed to allocate scarce medical resources.46,47 In the US health care system today, inpatient hospital beds can be viewed as a scarce resource needed by both ED patients awaiting hospital admission and current inpatients who are occupying those beds. The first 24 hours have been identified as the most resource-intensive hours of a hospitalization; thus, many patients who present to the ED with conditions requiring hospital admission have their greatest need for specialized inpatient services such as advanced diagnostic tests, surgery, or intensive care in those initial hours after they present. If these acutely ill or injured patients are boarded for long periods in a crowded ED, they are at high risk for delays in treatment and for reduced attention, as emergency physicians and staff struggle to care for new patients as they arrive. In Volume , . : May
Moskop et al contrast, hospital inpatients near the end of their hospitalization, who are often awaiting nursing home placement or social work assistance in obtaining important medical equipment, probably have the lowest need for hospital care. Despite their reduced need for care, however, these patients continue to occupy an inpatient bed. Thus, the principle of access to health care based on urgency or magnitude of need appears to dictate that inpatient care be reallocated from current inpatients nearing discharge to ED patients awaiting hospital admission. Unfortunately, a limited number of long-term care facilities (partly as a result of inadequate compensation),48 combined with the inability or unwillingness of family members to care for the patient in a home setting, leaves the hospital as the provider of last resort for medically stable patients recuperating from illnesses that initially required hospitalization. Policymakers, politicians, and others in society will need to confront this issue as the elderly comprise an ever larger percentage of our population. A second widely held principle of distributive justice in health care asserts that access to care should be based on medical criteria and not on social or economic criteria such as ethnicity, religion, sex, age, disability, sexual orientation, income level, or insurance status. Partial affirmation of this principle can be found in the federal EMTALA requirement that EDs provide a screening examination and stabilizing treatment for all patients with emergency medical conditions.19 Patients admitted to the hospital through the ED may differ significantly in several of these social and economic criteria from patients admitted through other mechanisms, eg, direct admissions, scheduled surgeries, planned transfers. Thus, de facto, ED patients may be discriminated against if they are, as a matter of policy or routine practice, assigned a low priority for access to inpatient beds. As noted above, ED crowding is one consequence of decisions about the distribution of health care resources, and thus it raises questions of distributive justice. These questions arise on multiple levels. At the societal level, for example, national, state, and local governmental officials decide who will be guaranteed access to what kinds of health care and what public resources will be invested in the construction and staffing of hospitals and other health care facilities. At the institutional level, hospitals formulate policies and procedures for the admission and discharge of patients, open new hospital units to relieve crowding or to provide new patient services, and close other units where demand or reimbursement is insufficient. At the individual level, hospital admissions officers, in consultation with emergency physicians and other providers, determine which of several waiting patients will be assigned the next available inpatient bed. If hospital EDs in the United States have a moral and legal mandate to provide quality emergency care to all who need it, it is important that emergency physicians and nurses make governmental and institutional leaders aware of the significant problem of ED crowding and that they participate in efforts to address this problem. Several such efforts are described in part 2 of this article. Volume , . : May
Concept, Causes and Moral Consequences of Crowding In addition to its negative effects on patients, the experience of observing frequent delays in care and of evaluating and treating patients in areas without privacy has serious short- and long-term consequences for providers, including decreased job satisfaction, frustration, anger, depression, and ultimately burnout.49 These are classic reactions to ethical dilemmas that resist solution. Emergency physicians expect occasional situations in which resources are not adequate for the needs of patients, and they are prepared to manage these situations as effectively as possible. Health care professionals may not be able to sustain a constructive response, however, when ED crowding persists despite their ongoing best efforts to alleviate this problem. Because the concept, causes, and consequences of ED crowding are not fully understood, a robust research agenda on this topic remains to be pursued.50 Enough is understood, however, for the IOM to conclude that ED crowding now constitutes a national crisis. In part 1 of this 2-article series, we have emphasized the moral significance of the crisis of ED crowding. Part 2 of the series will identify and analyze barriers to resolving this crisis and various strategies proposed to overcome those barriers. For the ACEP Ethics Committee. Supervising editor: Robert K. Knopp, MD Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Earn CME Credit: Continuing Medical Education is available for this article at: www.ACEP-EMedHome.com. Publication dates: Received for publication May 21, 2008. Revision received September 10, 2008. Accepted for publication September 22, 2008. Available online November 11, 2008. Reprints not available from the authors. Address for correspondence: John C. Moskop, PhD, Department of Medical Humanities, The Brody School of Medicine, 600 Moye Boulevard, Greenville, NC 27834; 252744-2617, Fax 252-744-2319; Email [email protected].
REFERENCES 1. Institute of Medicine, Committee on the Future of Emergency Care in the United States Health System. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: National Academy Press; 2006. Executive summary available at: http://www.nap. edu/catalog/11621.html. Accessed February 15, 2008. 2. Nawar EN, Niska RW, Xu J. National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary. Advance data from vital and health statistics 2007 (June 29); No. 386. Available at: http://www.cdc.gov/nchs/data/ad/ad386.pdf. Accessed February 15, 2008.
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Concept, Causes and Moral Consequences of Crowding 3. AHA Hospital Statistics. Chicago, IL: Health Forum; 2008. 4. Gallagher EJ, Lynn SG. The etiology of medical gridlock: causes of emergency department overcrowding in New York City. J Emerg Med. 1990;8:785-790. 5. Andrulis DP, Kellermann A, Hintz EA, et al. Emergency departments and crowding in United States teaching hospitals. Ann Emerg Med. 1991;20:980-986. 6. American College of Emergency Physicians. Hospital and emergency department overcrowding. Ann Emerg Med. 1990;19: 336. 7. Measures to deal with emergency department overcrowding. American College of Emergency Physicians. Ann Emerg Med. 1990;20:944-945. 8. American College of Emergency Physicians. Crowding (policy statement). Approved January 2006. Available at: http://www.acep.org/practres.aspx?id⫽29156. Accessed February 15, 2008. 9. Asplin BR, Magid DJ, Rhodes KV, et al. A conceptual model of emergency department crowding. Ann Emerg Med. 2003;42:173180. 10. Pines JM. Moving closer to an operational definition for ED crowding [letter]. Acad Emerg Med. 2007;14:382-383. 11. Derlet RW, Richards JR, Kravitz RL. Frequent overcrowding in US emergency departments. Acad Emerg Med. 2001;8:151-155. 12. Reeder TJ, Garrison HG. When the safety net is unsafe: real time assessment of the overcrowded emergency department. Acad Emerg Med. 2001;8:1070-1074. 13. Bernstein SL, Verghese V, Leung W, et al. Development and validation of a new index to measure emergency department crowding. Acad Emerg Med. 2003;10:938-942. 14. Weiss SJ, Derlet R, Arndahl J, et al. Estimating the degree of emergency department overcrowding in academic medical centers: results of the National ED Overcrowding Study (NEDOCS). Acad Emerg Med. 2004;11:38-50. 15. Asplin BR, Rhodes KV, Flottemesch TJ, et al. Is this emergency department crowded? a multicenter derivation and evaluation of an emergency department crowding scale (EDCS). Acad Emerg Med. 2004;11:484-485. 16. McCarthy ML, Aronsky D, Jones ID, et al. The emergency department occupancy rate: a simple measure of emergency department crowding? Ann Emerg Med. 2008;51:15-24. 17. Jones SS, Allen TL, Flottemesch TJ, et al. An independent evaluation of four quantitative emergency department crowding scales. Acad Emerg Med. 2006;13:1204-1211. 18. Hoot NR, Zhou C, Jones I, et al. Measuring and forecasting emergency department crowding in real time. Ann Emerg Med. 2007;49:747-755. 19. Emergency Medical Treatment and Active Labor Act. 42 USC 1395dd et seq. 20. Olshaker JS, Rathlev NK. Emergency department overcrowding and ambulance diversion: the impact and potential solutions of extended boarding of admitted patients in the emergency department. J Emerg Med. 2006;30:351-356. 21. United States General Accounting Office. Emergency departments: unevenly affected by growth and change in patient use. Report to the Chairman, Subcommittee on Health for Families and the Uninsured, Committee on Finance, US Senate, January 1993. Available at: http://161.203.16.4/d36t11/ 148331.pdf. Accessed February 15, 2008. 22. Trzeciak S, Rivers E. Emergency department overcrowding in the United States: an emerging threat to patient safety and public health. Emerg Med J. 2003;20:402-405. 23. Espinosa G, Miro O, Sanchez M, et al. Effects of external and internal factors on emergency department overcrowding [letter]. Ann Emerg Med. 2002;39:693-695.
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Moskop et al 24. Schull MJ, Kiss A, Szalai J-P. The effect of low-complexity patients on emergency department waiting times. Ann Emerg Med. 2007; 49:257-264. 25. Forster AJ, Stiell I, Wells G, et al. The effect of hospital occupancy on emergency department length of stay and patient disposition. Acad Emerg Med. 2003;10;127-133. 26. Rathlev NK, Chessare J, Olshaker J, et al. Time series analysis of variables associated with daily mean emergency department length of stay. Ann Emerg Med. 2007;49:265-272. 27. McCabe J. Emergency department overcrowding: a national crisis. Acad Med. 2001;76:672-674. 28. Agrawal S. Emergency department crowding: an ethical perspective. Acad Emerg Med. 2007;14:750-751. 29. Kelen GD, Scheulen JJ. Commentary: emergency department crowding as an ethical issue. Acad Emerg Med. 2007;14:751754. 30. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 5th ed. New York, NY: Oxford University Press; 2001. 31. Jonsen AR. Do no harm: axiom of medical ethics. In: Spicker SF, Engelhardt HT Jr, eds. Philosophical Medical Ethics: Its Nature and Significance. Dordrecht, Holland: D. Reidel Publishing Company; 1977:27-41. 32. Joint Commission. Delays in treatment. Sentinel event alert 2002 (June 17); issue 26. Available at: http://www.jointcommission. org/SentinelEvents/SentinelEventAlert/sea_26.htm. Accessed February 15, 2008. 33. Sprivulis PC, DaSilva JA, Jacobs IG, et al. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust. 2006;184:208-212. 34. Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust. 2006;184:213-216. 35. Croskerry P, Sinclair D. Emergency medicine: a practice prone to error. Can J Emerg Med. 2001;3:271-276. 36. Schull MJ, Vermeulen M, Slaughter G, et al. Emergency department overcrowding and thrombolysis delays in acute myocardial infarction. Ann Emerg Med. 2004;44:577-585. 37. Stolte E, Iwanow R, Hall C. Capacity-related interfacility patient transports: patients affected, wait times involved and associated morbidity. Can J Emerg Med. 2006;8:262-268. 38. Diercks DB, Roe MT, Chen AY, et al. Prolonged emergency department stays of non-ST-segment-elevation myocardial infarction patients are associated with worse adherence to the American College of Cardiology/American Heart Association guidelines for management and increased adverse events. Ann Emerg Med. 2007;50:489-496. 39. Fee C, Weber EJ, Maak CA, et al. Effect of emergency department crowding on time to antibiotics in patients admitted with community-acquired pneumonia. Ann Emerg Med. 2007;50:501509. 40. Wilper AP, Woolhandler S, Lasser KE, et al. Waits to see an emergency department physician: US trends and predictors, 1997-2004. Health Aff (Millwood). 2008;27:w84-w95. Published online January 15, 2008; doi:10.1377/hlthaff.27.2.w84. 41. Pines JM, Hollander JE. Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med. 2008;51:1-5. 42. Burt CW, McCaig LF, Valverde RH. Analysis of ambulance transports and diversions among US emergency departments. Ann Emerg Med. 2006;47:317-326. 43. Pham JC, Patel R, Millin MG, et al. The effects of ambulance diversion: a comprehensive review. Acad Emerg Med. 2006;13: 1220-1227.
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Moskop et al 44. Moskop JC, Marco CA, Larkin GL, et al. From Hippocrates to HIPAA: privacy and confidentiality in emergency medicine—part I: conceptual and legal foundations. Ann Emerg Med. 2005;45:53-59. 45. US Department of Health and Human Services, Office for Civil Rights. Summary of the HIPAA privacy rule. Available at: http:// www.hhs.gov/ocr/privacysummary.pdf. Accessed February 15, 2008. 46. Iserson KV, Moskop JC. Triage in medicine, part I: concept, history, and types. Ann Emerg Med. 2007;49:275-281.
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Concept, Causes and Moral Consequences of Crowding 47. Moskop JC, Iserson KV. Triage in medicine, part II: underlying values and principles. Ann Emerg Med. 2007;49:282-287. 48. The coming crisis of long-term care. Lancet. 2003;361:1755. 49. Rondeau KV, Francescutti LH. Emergency department overcrowding: the impact of resource scarcity on physician job satisfaction. J Healthc Manag. 2005;50:327-340. 50. Bernstein SL, Asplin BR. Emergency department crowding: old problem, new solutions. Emerg Med Clin North Am. 2006;24:821837.
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