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Since the earliest reports of the phenomenon of emergency department (ED) crowding, this problem has increased from what was perceived initially as a sporadic issue affecting only large, urban, academic centers to a national dilemma affecting all EDs and, by extension, threatening the national safety net of emergency care. In part, the growing appreciation of the problem of ED crowding is also a story of the changing role of the ED and its relationship to the greater US health care system. In this month’s Annals, Pitts et al report on an analysis showing that ED crowding has been increasing and suggesting that the primary cause is related to a greater practice intensity on the part of emergency providers. We argue that these findings are a perfectly predictable response to a dysfunctional health care system. Almost 10 years ago, Annals published a conceptual model of ED crowding that provided a framework that could be used to understand and study the phenomenon. The model suggested that patient flow through the ED can be conceived of as components of input, throughput, and output and that crowding resulted from dysfunction at points along this process. During the last decade, the specialty of emergency medicine has worked tirelessly to understand the causes and consequences of ED crowding, design solutions, and advocate for system changes to alleviate the problem. Famously now, the 2006 Institute of Medicine report Hospital-Based Emergency Care: At the Breaking Point described crowding as a “national epidemic.” As a result, we have studies dispelling the myth that low-acuity patients contribute significantly to crowding or that the ED is crowded because of uninsured or frequent users. There are also reams of important work connecting crowding and boarding to negative patient outcomes and noting its adverse effect on national preparedness planning and surge capacity. In addition, our specialty has explored ways to improve the efficiency of front-end operations to reduce length of stay and ameliorate the effects of crowding, as well as model hospital strategic responses to periods of extreme l |
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