Hospital emergency department capacity may be reaching its limits

Emergency physicians fear increased gridlock as already overcrowded facilities brace for flu season.

By Kathleen F. Phalen, amednews correspondent. Jan. 15, 2001.

Emergency departments around the nation are stretched to capacity, so doctors expect the unexpected -- even a wild card like this year's flu season -- to upset an already fragile situation.

"Staff is pushed to the edge when they are wall-to-wall with the critically ill [patients] and more are en route. ... During the last flu outbreak, eight, nine, 10 metropolitan acute care hospitals were on diversion at one time," says Arthur Kellerman, MD, chair of the Dept. of Emergency Medicine at Emory University School of Medicine in Atlanta, and a member of the board of the American College of Emergency Physicians. "We thought the situation would abate after the flu season, but it didn't.

"When there aren't enough staffed hospital beds, the system backs up and we get on the verge of gridlock. Around the nation, there are thousands of sick and injured patients in hallways with nowhere to go."

A number of issues -- funding, staffing, patients' lack of insurance -- contribute to what Dr. Kellerman calls gridlock. But, as he explains, emergency department overcrowding is really a symptom of an inpatient problem. "It's not a matter of just buying more gurneys or ambulances," he says. "There just aren't enough acute care beds to meet the need, so [those patients] get boarded in the ED. At that point, staff is working under incredible stress. If we had available staffed beds in the hospital, there would be no overcrowding. The system works beautifully when the inpatient system is working."

With the flu season coming late this year, it's hard to predict what will happen, says Michael Osterholm, PhD, chair of the Emerging Infections Committee of the Infectious Diseases Society of America. "Clearly there are a variety of different situations by geographic area, but guesstimates are that at least half of the country is experiencing this situation," he says. "We're trying to prepare, but we don't really know the extent of the problem and, unfortunately, infectious diseases represent the unexpected."

Influenza-related diversion is a symptom of a much larger problem, Dr. Osterholm says. "We're all talking about preparing for pandemic flu and domestic terrorism, but how can we prepare if we don't have the data? Data are golden, but we don't have them, and no one is in charge," he says. "There's going to be a point, eventually, that there will be ambulances with no place to go. ... It's like trying to run O'Hare's air traffic control with tin cans and string."

The flu: Adding to the pressure

According to Rick Wade, senior vice president of the American Hospital Assn. in Washington, D.C., doctors exacerbate ED pressures during flu season. "Patients with the flu call the doctor's office and are told to go to the ED," he says. "In preparing for this flu season we are working with doctors, encouraging them to administer more vaccines and to follow protocols for admission."

But Dr. Kellerman says it's not the simple colds and flu but rather the respiratory and heart complications of flu that cause ED overcrowding. The way he explains it, the colds get sent home. It's the seriously ill who need hospital beds -- and when there are no beds, gridlock begins.

Trauma centers are the hardest hit. "There may be over-bedded suburban hospitals, but you can't divert a trauma patient to a community hospital," Dr. Kellerman says. "It's the critically ill patients who can't get admitted. We're operating at absolute margins of daily capacity; then, when the critical start rolling in the door, we have problems. But if all hospitals are on divert, then no one is on divert, and they rotate the patients among the hospitals."

Getting a handle on things requires bottom-up cooperation, Dr. Osterholm says. "It's a local issue first. In many communities there isn't cooperation among hospitals."

Perhaps that was part of the problem in northern Virginia. Diversions were all too common, and it was frustrating for emergency medical services crews. So the region's EMS, hospitals and emergency personnel got together to change things. Effective as of November 2000, unless an ED is falling apart, there is no diversion.

"The problem shouldn't be in the back of the ambulance but at the hospital," says Glenn Druckenbrod, MD, medical director of the emergency department at Inova Fairfax Hospital in Falls Church, Va. "Every hospital is running at or over capacity, and any little thing is a problem. But now, instead of the medics trying to find someone to take the patient, they go to the most appropriate hospital."

At Inova Fairfax, like many trauma centers, about 25% of emergency patients are admitted. That's one in four, so they are very aggressive about moving patients through, says Dr. Druckenbrod. If a patient has to wait more than eight hours in the ED for a bed, he says, they have failed that patient.

The hospital's "Be a Bed Ahead" program is really helping. "We meet every day and talk about beds," Dr. Druckenbrod says. "We are trying to get doctors to discharge in the morning, to get patients through lab and radiology faster and always know the next available bed."

As far as the flu, Dr. Druckenbrod is not sure what will happen. "With the delay of the flu vaccine, we have to wait and see," he says.

"We run so close to capacity, we're not sure if that will make a difference. We have put on extra staff, and we're trying to turn beds faster, but we just don't know."