2 Top Reasons EDs Are Overcrowded

Homelessness Mental Illness

Overcrowding is the most pressing issue facing emergency departments (EDs) today. When an ED is at — or over — capacity, quality of care, patient safety and staff morale all begin to suffer.

There are many reasons why EDs experience overcrowding. While this blog focuses on two of the biggest culprits, it’s important to understand that a variety of factors, both internally within the ED and externally in the community, contribute to this growing problem.

Here are two of the most common issues contributing to overcrowding in the ED, and a few suggestions to help EDs tackle the problem head on.

1. Homelessness

A 2002 study conducted by the American Public Health Administration found that more than 40 percent of the homeless respondents it surveyed had visited an ED at least once over the course of a year. (Nearly eight percent visited on three or more separate occasions.) Fast forward 10 years and not much has changed. This study from 2013 found that single homeless women visited the ED 13 times more often than women in the general population. For single homeless men, the rate was nine times higher than the general population.

While homeless individuals make up a small fraction of the overall population in the U.S., the frequency of ED use by the homeless takes it toll when it comes to crowding.

What can EDs do? First, they must ensure that they have a strong patient flowprocess in place. Optimized patient flow is the first step to eliminating overcrowding, regardless of the cause.

Second, it’s important to build relationships with organizations within the community that can offer assistance to homeless patients once they’re discharged. Make sure you have a list of shelters, mental health and substance abuse professionals, food pantries and other related organizations at the ready. Often, the most effective treatment is to empower patients with information on where they can seek assistance.   

2. Substance Abuse, Mental Health and Psychiatric Boarding

Much like homelessness, patients battling mental health and substance abuse issues find themselves in the ED more often than the general population. In 2007,1 in 8 ED visits were made by adults with a mental health or substance abuse problem. The role of the ED is to perform emergency medicine, not provide long-term treatment for those patients suffering from these chronic problems. But in reality, EDs are on the frontline when it comes to treating the effects.

To help patients with mental health or substance abuse problems — and stem their repeated visits to the ED — EDs should serve as a guide to outside resources and organizations that can offer long-term assistance. Just as with homeless patients — many who may be suffering from mental health and substance abuse-related medical issues — the ED best serves as an intermediary.

The boarding, or holding for treatment, of psychiatric patients is another issue contributing to the crowding of EDs. According to Dr. Scott Zeller, chief of Psychiatric Emergency Services for the Alameda Health System in Oakland, California, ED staff spend twice as much time trying to find in-patient beds for psychiatric patients than they do other patients.

Dr. Zeller says, “Often these patients are kept with a sitter, or in ‘holding rooms’ or hallways on a gurney, some languishing for hours in physical restraints, often with no concurrent active treatment.”

As a solution, he recommends regional dedicated emergency psychiatric facilities that are EMTALA compliant. Patients could go to these centers on their own to seek care, be taken by ambulance when mental health is a concern or transferred there from hospitals that don’t offer psychiatric care once medically stabilized. They could be treated right away rather than spend hours waiting in an ED bed.

Zeller’s suggestion is that the problem should be treated at the source — when patients first present, rather than at the destination — once admitted to the hospital after hours of waiting, boarded in an ED. He sites that a great majority of psychiatric emergencies can be stabilized in less than 24 hours. In his model study, patient boarding times decreased significantly — by more than eight hours, an 80 percent improvement.

How to Solve Overcrowding in Your ED
These two factors which contribute to ED overcrowding have distinct characteristics that call for customized solutions. There’s not a single, universal course of action EDs can take to address overcrowding. Only by stepping back and taking into account all the factors at play, can EDs begin to tailor a specific plan of action.

If your ED is facing issues related to overcrowding, Donovan and Partners can assess your ED and uncover the reasons why. We’ll examine your triage process, staffing and patient flow, along with external issues facing your community, and then help you implement the best solutions to alleviate crowding. Contact us today at cmd@constancedonovan.com or 651-260-9918. For more information on the services we offer, visit our website.

American Public Health Association: “Emergency Department Use Among the Homeless and Marginally Housed: Results From a Community-Based Study.”

Science Daily: “Homeless people more frequent users of ED, other health services.”

Medscape Medical News: “Mental Disorders, Substance Abuse Linked to Increased Emergency Department Visits.”

Zeller, Scott: “Psychiatric Patient Boarding Problems in the Emergency Department.”