Emergency Department Crowding in California: A Silent Killer?

Abstract

In this issue of Annals, Sun et al report on the association between emergency department (ED) crowding and 3 important outcomes—mortality, hospital length of stay, and costs—in a broad cohort of admissions in 187 California hospitals in 2007. Patients admitted on days with high crowding, measured as the top quartile of ambulance diversion, had a 5% higher chance of death, an almost 1% longer hospital stay, and 1% higher costs per admission, after adjusting for other factors. The estimate of the human and financial costs attributable to ED crowding was 300 additional inpatient deaths, 6,200 excess hospital days, and $17 million extra. Circa 2013, walk into the average large, inner-city, US hospital ED on a Monday afternoon, California or not, and the typical scene is a packed waiting room with hallways lined with sick and injured patients. Admitted patients are boarding for hours, many left untended or certainly not carefully watched, while harried staff scurry furiously to treat new, potentially ill patients. To the average emergency care provider, the harmful effect of this daily dysfunction found in the authors’ article probably comes as no big surprise. But the first reports of crowding in US EDs emerged in the late 1980s and early 1990s. Now, more than 20 years later, the first published claims-based, US-based, health services research report links what may seem to an everyday person to be an obviously unsafe environment to negative patient outcomes. It is also notable that in the last 2 decades, the term “ED crowding” has become somewhat outdated with the realization that one of the main causes of ED crowding is “hospital crowding” and its result: prolonged boarding of admitted patients in the ED. This raises the question, why has it taken so long to link ED and hospital crowding with poor outcomes in the United States and put stark evidence-based estimates on its human and economic tolls? Well, there are several reasons. First, in any health service research study, one of the goals is to link an “X,” an exposure, to a “Y,” the outcome. The relationship between ED crowding and outcomes has been elusive because there are both X problems and Y problems. f