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ED Visits Continue to Escalate

In 2002, more than 110 million visits were made to emergency departments nationwide—an increase of more than 3 million over the previous year, according to a new report from the Centers for Disease Control and Prevention (CDC). This trend is likely to continue, according to the American College of Emergency Physicians (ACEP).

The CDC found two-thirds of emergency patients spent 1–6 hours in the ED, with the average visit lasting 3.2 hours. The report also highlighted last year’s General Accounting Office report, which found the inability to move patients out of the ED into hospital beds (known as “boarding”) a key indicator contributing to overcrowding.

“One ridiculously simple thing has to happen: Admitted patients have to get out of the ED,” says ACEP member Peter Viccellio, MD, director of the emergency department at Stony Brook University Hospital in New York. “All the stuff you hear about unnecessary visits, EMTALA and safety nets really has more to do with inadequate funding than inadequate space.”

Some hospitals, including Stony Brook, have taken steps to alleviate the crowded waiting rooms, says Viccellio.

“We thought, if we can put patients in our small hallway space, why can’t the hospital move them to their huge amount of hallway space? That’s what we do, and it’s helped relieve congestion, cuts down the waiting time for patients and it’s a model that’s currently growing in the United States. Solutions are driven by your premises to a large degree, and we operate on the premise that the ED is an essential service to the community and diversion is not an option. There has to be another choice than closing the ED.”

Although ACEP recently released an educational flier to be distributed to patients in EDs, Viccellio thinks it will have little positive impact. “The reasons people decide to come to the ED are extraordinarily complex,” he says. “The track record in terms of published material giving people advice about when to come to the ED tends to do two things: It increases the number of times somebody comes in, or it increases the odds of a misadventure—that someone who is sick becomes reluctant to come in. I’d rather see people who don’t need to be there than to miss someone who does.”

Much of the problem can be attributed to the nursing shortage, says Viccellio. “In 1988, New York state graduated 20,000 nurses; five years ago, they graduated 5,000 nurses,” he says. “We’re looking at an aging nursing population with no providers coming up to replace them. And, there’s a population that’s aging who will need more intensive medical care, so we have a perfect storm brewing. As far as I’ve been able to see, there’s been about 10 years of posturing and hand-waving with no beginnings of an effort to address the problem. It was like that with ED overcrowding. For 20 years, we postured and waved hands, but had no solution. There’s now at least a partial solution by booting people out of the ED and into the hospital, which is a discreet step that has a significant impact. But the nursing shortage is going to become catastrophic.”

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