ENGLISH TASK

DEBATE ABOUT EMERGENCY DEPARTMENT

Created by:

1. Grita Cyntia Dewi (P27820714008)

2. Anindya Hidayaturrohma (P27820714011)
3. Ichtiyar Rizki Z (P27820714019)
4. Hariyani Safitri (P27820714035)

STUDY PROGRAM DIV EMERGENCY NURSING

POLITEKNIK KESEHATAN KEMENTERIAN KESEHATAN
SURABAYA
TAHUN AKADEMIK 2015/2016
 INTRODUCTION

Definition
An emergency department (ED), also known as an accident & emergency
department (A&E), emergency room (ER) or casualty department, is a medical
treatment facility specializing in emergency medicine, the acute care of patients
who present without prior appointment; either by their own means or by that of an
ambulance. The emergency department is usually found in a hospital or other
primary care center.
Due to the unplanned nature of patient attendance, the department must
provide initial treatment for a broad spectrum of illnesses and injuries, some of
which may be life-threatening and require immediate attention. In some countries,
emergency departments have become important entry points for those without other
means of access to medical care. The emergency departments of most hospitals
operate 24 hours a day, although staffing levels may be varied in an attempt to
reflect patient volume.
Critical Conditions handled in emergency department are Cardiac arrest,
Heart attack (Myocardial infarction), mental illness, asthma and COPD.

History
Accident services were already provided by workmen's compensation plans,
railway companies, and municipalities in Europe and the United States by the late
mid-nineteenth century, but the first specialized trauma care center in the world was
opened in 1911 in the United States at the University of Louisville Hospital in
Louisville, Kentucky, and was developed by surgeon Arnold Griswold during the
1930s. Griswold also equipped police and fire vehicles with medical supplies and
trained officers to give emergency care while in route to the hospital.
Today, a typical hospital has its emergency department in its own section of
the ground floor of the grounds, with its own dedicated entrance. As patients can
present at any time and with any complaint, a key part of the operation of an

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emergency department is the prioritization of cases based on clinical need. This
process is called triage.
Triage is normally the first stage the patient passes through, and consists of a
brief assessment, including a set of vital signs, and the assignment of a "chief
complaint" (e.g. chest pain, abdominal pain, difficulty breathing, etc.). Most
emergency departments have a dedicated area for this process to take place, and
may have staff dedicated to performing nothing but a triage role. In most
departments, this role is fulfilled by a triage nurse, although dependent on training
levels in the country and area, other health care professionals may perform the triage
sorting, including paramedics or physicians. Triage is typically conducted face-to-
face when the patient presents, or a form of triage may be conducted via radio with
an ambulance crew; in this method, the paramedics will call the hospital's triage
center with a short update about an incoming patient, who will then be triaged to
the appropriate level of care.
Most patients will be initially assessed at triage and then passed to another
area of the department, or another area of the hospital, with their waiting time
determined by their clinical need. However, some patients may complete their
treatment at the triage stage, for instance if the condition is very minor and can be
treated quickly, if only advice is required, or if the emergency department is not a
suitable point of care for the patient. Conversely, patients with evidently serious
conditions, such as cardiac arrest, will bypass triage altogether and move straight
to the appropriate part of the department.
The resuscitation area, commonly referred to as "Trauma" or "Resus", is a
key area in most departments. The most seriously ill or injured patients will be dealt
with in this area, as it contains the equipment and staff required for dealing with
immediately life-threatening illnesses and injuries. Typical resuscitation staffing
involves at least one attending physician, and at least one and usually two nurses
with trauma and Advanced Cardiac Life Support training. These personnel may be
assigned to the resuscitation area for the entirety of the shift, or may be "on call"
for resuscitation coverage (i.e. if a critical case presents via walk-in triage or
ambulance, the team will be paged to the resuscitation area to deal with the case
immediately). Resuscitation cases may also be attended by residents, radiographers,

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ambulance personnel, respiratory therapists, hospital pharmacists and/or students
of any of these professions depending upon the skill mix needed for any given case
and whether or not the hospital provides teaching services.
Patients who exhibit signs of being seriously ill but are not in immediate
danger of life or limb will be triaged to "acute care" or "majors," where they will be
seen by a physician and receive a more thorough assessment and treatment.
Examples of "majors" include chest pain, difficulty breathing, abdominal pain and
neurological complaints. Advanced diagnostic testing may be conducted at this
stage, including laboratory testing of blood and/or urine, ultrasonography, CT or
MRI scanning. Medications appropriate to manage the patient's condition will also
be given. Depending on underlying causes of the patient's chief complaint, he or
she may be discharged home from this area or admitted to the hospital for further
treatment.
Patients whose condition is not immediately life-threatening will be sent to
an area suitable to deal with them, and these areas might typically be termed as a
prompt care or minors area. Such patients may still have been found to have
significant problems, including fractures, dislocations, and lacerations requiring
suturing. Children can present particular challenges in treatment. Some departments
have dedicated pediatrics areas, and some departments employ a play therapist
whose job is to put children at ease to reduce the anxiety caused by visiting the
emergency department, as well as provide distraction therapy for simple
procedures.
Many hospitals have a separate area for evaluation of psychiatric problems.
These are often staffed by psychiatrists and mental health nurses and social workers.
There is typically at least one room for people who are actively a risk to themselves
or others (e.g. suicidal). Fast decisions on life-and-death cases are critical in hospital
emergency rooms. As a result, doctors face great pressures to over test and over
treat. The fear of missing something often leads to extra blood tests and imaging
scans for what may be harmless chest pains, run-of-the-mill head bumps, and non-
threatening stomach aches, with a high cost on the Health Care system.

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 DISCUSSION

Emergency Department Overcrowding

Emergency Department overcrowding has become a national problem and is
now a chronic state in many departments. Although ED overcrowding is an obvious
concern for emergency medicine health care professionals, it truly is a health system
issue. ED overcrowding is a measure of health system performance and the
monitoring of overcrowding should be part of a focus on measurement of quality in
health care.
Emergency department crowding is one of the leading problems facing
emergency physicians, nurses, and their patients, in most developed countries. It
has been proposed that emergency department crowding is the equilibrium state of
the current health care system. While this may be so, it is not safe; there is a large
body of evidence that patients are harmed in crowded emergency departments.
Crowded departments threaten delivery of timely care. Delays to analgesia,
antibiotic therapy, and thrombolysis or percutaneous coronary intervention are all
well described. Compliance with other recognised care standards is reduced.
Regular medications are omitted in elderly frail patients. One author has estimated
that more people die avoidably as the result of crowding in New Zealand than in
road traffic collisions. Similar opinions have been expressed by Australian authors,
though the weakness of the underlying evidence is acknowledged. Patients with
more complex needs are more likely to board in the emergency department. Studies
have shown that frail, elderly patients and critically ill patients are more likely to
spend disproportionate time boarding in the emergency department. Crowding also
impairs dignity, privacy, and completeness of care.
A crowded emergency department creates problems beyond that department.
Ambulance crews are unable to unload their patient. This reduces resilience and the
capacity of prehospital services to respond to calls. Patients harmed by crowding in
an emergency department continue to suffer after they have been admitted. There
is some evidence that patients admitted through crowded emergency departments
have longer hospital stays. Emergency patients are also more likely to be admitted

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when the emergency department is crowded. This is most likely because the
emergency departments ability to safely discharge patients is compromised.
Crowding also harms staff. There are associations with absenteeism, staff
sickness, and burnout. This results in experienced staff leaving and more junior
staff, or agency staff delivering an increasingly busy and inefficient service.
Resident and student education is compromised. Recruitment is harmed. Despite a
large literature describing the consequences of crowding, there is little consensus
on a definition for crowding. The term overcrowding should be abandoned, as
any crowding is harmful. Defining crowding is important, as it allows
measurement, subsequent research, and policy evaluation. There are other
measures; simple bed occupancy has face validity and compares moderately to
other scales. Simply counting the number of patients who leave before treatment is
simple, but ignores the complexity of crowding.
There are a number of crowding scales in the literature, though many are
limited by being country specific or lack a gold standard in development and are
incompletely validated. These mainly aim to quantify crowding. Our research group
(KB and AB) have developed an eight points operational definition, and we are
working to validate this measure. There are four other scales in the literature, all of
which perform moderately with clinicians perceptions of crowding.

Causes of Crowding
Crowding is caused by multiple factors. These can be best thought of in
terms of input, throughput, and output. Asplins conceptual model illustrates the
stages that can lead to emergency department crowding. Input factors include not
only the volume, but also the acuity and type of patients. Worldwide the volume of
patients attending emergency departments has increased dramatically over the last
20 years. The reasons for this are not well understood. Primary care has also seen a
substantial increase in activity in the same time period. Older people, a growing
group, typically require disproportionate care. Patients with mental illness and
critical care patients require extensive emergency department care. A small increase
in any of these groups has a knock-on effect. Inappropriate attenders, a judge
mental term for patients who could receive medical care elsewhere, do not

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significantly contribute to crowding. Input problems need not cause crowding if the
rest of the emergency admission and discharge process works well.
Through put factors refer to activities within the emergency department that
can hinder patient flow. Emergency departments are extremely complex systems
and almost any activity can lead to crowding. Poor emergency department design,
which does not support flow, contributes to crowding. A linearly designed
emergency department, where cubicles flank a long straight corridor, is probably
most efficient. Having adequate physical space helps. However, merely increasing
cubicle spaces does not reduce crowding if processes within the department and in
the main hospital are not improved. Delays with diagnostic imaging and laboratory
results may contribute to crowding. Inadequate numbers of medical and nursing
staff may also be a factor. Increasingly stringent care standards for conditions such
as sepsis, transient ischaemic attack and stroke have increased the workload of
emergency departments. Patient and professional expectations are higher. Analysis
of the separate components of the time patients spend in the emergency department
has shown that waiting comprises 5163% of total patient turnaround time. Major
components are time away for radiological investigations, waiting time for the first
physicians examination, and waiting time for blood work. Output factors are the
main cause of emergency department crowding. Lack of inpatient beds is the single
most important cause of crowding. A lack of critical care beds leads to high acuity
patients remaining in the emergency department. Worldwide the trend has been to
reduce inpatient bed capacity. Quality standards such as single sex compliance in
the NHS, and infection control policies, have further contributed, though they are
difficult to quantify. There is a potential for harm in that patients transferred as
outliers on other wards have longer stays and more harm this in turn reduces
hospital capacity and drives further crowding. There is a strong perception that
hospitals prioritise more lucrative elective work over emergency admissions.
ED overcrowding general causes are found outside the emergency
department. They include:
lack of beds for admitted patients
lack of access to primary care and specialist physicians
shortage of ED nursing and physician staff

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 increasing complexity and acuity of patients in the ED
lack of alternative advanced diagnostic testing and treatment facilities

Effects of Overcrowding
Recently there has been a renewed interest in patient safety and the effect of
medical error in the health system. Numerous international studies have shown that
on retrospective chart review the rate of medical error resulting in an adverse patient
outcome is from 3-16%, with at least half of these events potentially preventable.
An overcrowded emergency department is an environment with enormous potential
for medical error because of the intensity of decision making, inadequate facilities
when patients are cared for in hallways and waiting rooms, and the increased stress
on caregivers.
One of the most visible signs of ED overcrowding is the problem of ambulance
diversion, which has been documented to have negative effects on the quality of
health care. The final outcome of overcrowding is its effect on health care
professionals. The challenge over the next few years will be to retain our
experienced staff, and chronic overcrowding has a significant effect on ED staffing.
Over the past decade, emergency department (ED) crowding has occurred and
progressed. It has become a major topic of discussion at emergency medicine (EM)
conferences, such as those held annually by the Society for Academic Emergency
Medicine and the American College of Emergency Physicians. There has been
much recent media coverage, such as the Newsweek article, Code Blue for the
ER.1 Recently the Institute of Medicine published an extensive report on the
topic.2 While there is no question that many EDs are crowded, the myriad causes
of and solutions to crowding have been widely debated. In our opinion, multiple
factors contribute to ED crowding, and the relative contribution of each factor
varies between EDs. Circumstances differ between urban and rural hospitals, as
well as between county, academic, and private hospitals.3 We believe multiple
simultaneous steps are necessary to solve ED crowding.
We present 10 putative solutions with commentary on actions at our institution
to counter the problem:

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1) Expand Hospital Capacity
In 1946, at the end of World War II, the United States Congress addressed
concerns with deficiencies in hospital bed capacity and health services by
passing the Hill-Burton Act.4 This provided billions of dollars for hospital
construction across the country, with the goal of five inpatient beds per1,000
persons. This wave of hospital construction attracted more people to careers in
healthcare. Major funding ended in 1966, when the Medicare and Medicaid
programs became law. By providing increased hospital capacity for its citizens,
communities successfully attracted physicians, nurses and ancillary staff.
Since 1970, the ratio of inpatient hospital beds per population has declined
in the U.S. Unfortunately, with increasing numbers of uninsured and a
requirement that hospitals run profitably, the number of hospital beds per 1,000
persons has diminished over the past 20 years. According to the California
Healthcare Association, 70 hospitals closed in California between 1993 and
2003. Californias population grew by 13% during that time while acute care
hospital bed capacity dropped by 14%. Today in California there are only 1.9
beds per 1,000 persons.5 As a result, many hospitals are perpetually full with
admitted patients boarded in the ED. Boarding of inpatients in the ED is
unquestionably the leading cause of crowding. At times the ED at the University
of California, Davis has more boarded patients than new, ambulatory patients.
We have contacted legislative staff locally and nationally about resurrecting the
Hill-Burton Act to expand hospital capacity. This might be more appealing to
Americans rather than radical reform of the healthcare system, advocated by
some. Many health systems would welcome federal support to make this
possible.
Some might argue that increasing the number of hospital beds is not
needed because of decreased length of stay for patients admitted to hospital more
recently. We believe this is offset by the aging population and the number of
complex medical conditions not considered and/or treated shortly after World
War II. These includes chronic renal failure/dialysis, transplants, Hepatitis C,
Acquired Immune Deficiency Syndrome, cancer chemotherapy, acute coronary
syndrome and coronary artery bypass grafts, pacemakers, and many others.

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 Many patients who would have died quickly or at home decades ago are kept
alive for days to months, only to die in hospitals today.

2) Stop regulating hospitals to the extreme

Legislative mandates in California have decreased flexibility of
hospitals ED operations. In California, AB 394, mandated a fixed patient:nurse
ratio of 4:1 in the ED in 2004. In our opinion, enforcement of this fixed ratio has
been harmful rather than helpful to ED patients. In the past, during periods of
extreme crowding, ED patients might have been doubled up in some treatment
areas to provide the safest environment for monitoring. Now, with a rigid 4:1
patient: nurse ratio, patients are placed in hallways with no direct nursing
observation during periods of crowding. Indeed, some patients who are very ill
must remain in the waiting room. We believe this rule should be relaxed when
applied to the ED to allow for flexibility during periods of crowding. Some
hospital administrators have promised to float more nurses down to the ED
during periods of crowding. However, this has not been consistent, as it depends
on nurses acceptance. Most inpatient nurses refuse to work in the ED out of
personal preference.
Other mandates have placed undue emphasis on certain medical
conditions at the expense of others. For example, the requirement of early
administration of antibiotics for patients with pneumonia is notable.6 Naturally
this results in more focus on patients with pneumonia; however, an elderly
person presenting with abdominal pain or potential sepsis may be pushed further
to the back of the triage line as a result. Finally, requirement of state approval of
construction projects within hospitals results in increasing delay and expense.
Small changes in a hospitals physical structure to enhance patient flow are made
prohibitively expensive because of a gauntlet of lengthy state reviews.
Furthermore, attempts to modify existing parts of an ED to enhance capacity
trigger comprehensive review by the Office of Statewide Planning and
Development. This, in turn, requires the entire department to be brought up to
current code standards, making minor modifications difficult or impossible
because of added expense.

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3) Provide care only to patients with emergencies
Prior to the Emergency Medical Treatment and Active Labor Act
(EMTALA) in 1986, many individuals with bona fide medical emergencies were
turned away from the ED or transferred with incomplete care because they did
not have insurance. As a result, EMTALA was created to ensure all patients with
true emergencies were appropriately evaluated and stabilized. Over the past 20
years, this intent has been progressively over-interpreted by numerous regulators
throughout the Centers for Medicare & Medicaid Services (CMS) districts in the
United States. The requirement that all patients presenting to an ED must have a
medical screening exam has been interpreted by many as all patients must be
treated as well. With many of the population aware of such a mandate, patients
who have no access to general primary medical care are now utilizing the ED,
despite long waits. Some might debate whether the Safety Net philosophy of
the ED has increased the number of patients in the ED, while in our experience
this has definitely been the case.

We believe that EDs should exist for true emergencies, similar to the
notion that fire departments exist to extinguish fires. We think a more cost-
effective, appropriate, and efficient method of treating non-emergent medical
problems occurs in urgent or primary care clinics, provided these are available.
At one time, our ED actually referred out persons who presented with non-
emergent medical conditions. At our ED, we devised a system whereby over
five years we referred over 32,000 patients to ambulatory clinics after a medical
screening exam (MSE) by the triage nurse that determined these patients did
not have an emergency medical condition.7 In subsequent years after the
implementation of this referral system, referral clinics accepting non-funded
patients became nearly nonexistent, making it difficult to refer patients out. We
have also conducted a survey on how the general public defines a bona fide
emergency and concluded most believe the ED should be reserved for patients
with true emergencies.8 In order to successfully treat non-emergent patients,
additional primary care clinics must be built within most communities. These

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 clinics must be able to provide services for patients with and without health
insurance in order to share the patient load that currently leans heavily on the
ED. A number of Federally Qualified Health Centers (FQHC)-designated
clinics have opened in communities to assist with this effort, but many more
are needed.

4) Provide alternatives for primary care of the uninsured

Many county health departments do not have adequate ambulatory
clinic facilities for their uninsured patients. It is common knowledge these
patients will receive care in the local ED. Many uninsured and/or indigent
patients do not even bother using these clinics, but instead use the ED for primary
care. With their less acute triage categories these patients frequently have waits
as long as 12 hours. We have attempted to form a healthcare consortium of the
major health systems in the Sacramento area with the assistance of our county
health department to provide appropriate clinic facilities and care for patients
without insurance.

5) Stop boarding admitted patients in the Emergency Department

Limited hospital bed capacity results in the boarding of admitted
patients in the ED. Patients are placed in hallways, storage rooms, and annexes.
Some of these ED hallway patients are sicker than admitted patients already
occupying inpatient beds. Boarding of patients in the ED results in significant
ED congestion and is associated with poor outcomes.1012
In some academic centers door to floor time exceeds 21 hours for
90% of admitted patients. It would make sense then to move admitted patients
from ED hallways up to the hallways of the inpatient areas when the hospital is
full. Such a proposal is not novel and, in fact, is used extensively on the East
Coast. This has been championed by Dr. Peter Viccellio of the State University
of New York at Stony Brook.9 In that model, during periods of ED crowding
patients are automatically moved to inpatient hallways. One of the benefits is
that inpatient staff quickly accommodates these patients into appropriate
inpatient beds as soon as these become available.

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6) Use evidence-based guidelines to address imaging over utilization
When we first began practicing EM, the availability of computed
tomography (CT) was limited to patients with severe head and thoraco-
abdominal trauma. Today it seems we collectively order CT scans on 50% of all
patients during a shift, including those with minor head trauma, abdominal pain,
headache, and soft tissue complaints. We do believe the increased availability
and speed of CT has resulted in improved outcomes. However, a number of
studies have suggested that focused use of CT scans and other imaging tests can
be achieved without a negative impact on outcome.13 Indiscriminate ordering
of CTs may even be deleterious. It has been estimated that one cancer death
occurs for every 1,000 CTs performed on children.14 Patients waiting for
abdominal CT with oral contrast can occupy an ED bed for an additional four to
six hours in some institutions.
This is progressing now with routine magnetic resonance imaging
(MRI) for patients with symptoms of transient ischemic attack and/or
cerebrovascular accidents. Patients are now queued up for our MRI scanner,
further occupying beds and increasing waiting time for those not yet evaluated.
We believe careful criteria should be established for imaging, in particular the
use of abdominal CT for non-specific abdominal pain.

7) Change admitting patterns

One means of decreasing demand for scarce hospital and intensive care
unit (ICU) beds is to change admitting patterns. Some hospitals have established
services to provide specialty evaluation of patients with chest pain who
otherwise might be admitted. These patients may undergo same-day exercise
treadmill testing and be sent home if their results are normal. Intravenous (IV)
antibiotic infusion centers and home health nursing care may also help decrease
admissions. Additional measures may help preserve an even greater shortage of
telemetry and ICU beds. Some hospitals have adapted criteria that standardize
telemetry and ICU admissions. In addition, some patients who may have
required ICU care at the initial onset of the ED presentation may, in fact, need

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 lower level of care after ED treatment and stabilization. Many changes in
admission patterns have occurred in the past 20 years, but some of these do not
help the flow of ED patients. For example, in years past, most patients with
asthma were admitted, whereas now patients often receive intensive treatment in
the ED for six to 12 hours. This again prolongs the time to be seen for patients
in the waiting room.

8) Expand the role of ancillary ED staff and hallway care

A number of plans have sought to increase productivity of ED staff,
including physicians, nurses, and technicians, to counter crowding. An increase
in physician hours and coverage has limited benefit because the rate-limiting
factor has been nursing coverage. Strict adherence to the 4:1 patient:nurse ratio
obviates any advantage to increased physician coverage. Increasing nursing
coverage during a nursing shortage is difficult. Expanding utilization of licensed
vocational nurses (LVN) may be helpful. Not all hospitals use LVNs, and
nursing organizations have argued that nurses provide better patient safety. The
addition of family nurse practitioners and physician assistants to the ED staff
could also help reduce crowding. At our ED we now use the hallway as a major
patient-care area. To not do so would result in complete gridlock of the ED when
designated ED patient-care areas are filled with admitted patients and the
hospital is full. Patients who have been waiting hours to be seen are often grateful
to be evaluated regardless of location. However, in our opinion and experience,
hallway evaluations are by nature less complete for lack of privacy and space
and may have the potential for poor outcomes.

9) Call the nurse first

A number of companies, agencies, and healthcare institutions have
developed nurse assistance phone services to help triage patients to the ED or
clinic. A number of studies have shown these services are efficient and safe.15
However, these services are expensive to operate. A study group from Kansas
City showed that in a closed point-of-service population, potential ED visits
were diverted, thereby saving the health system money even when the cost of

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 the service was factored in.16 A large multi-city study of mixed patient
populations would be helpful to determine the utility of this approach to ED
crowding. If it is acceptable to advise a patient over the phone that ED care is
not necessary, why is so difficult to allow a registered nurse in ED triage to
assess a patient personally, and make the same conclusion?

10) Prevent disease and injury

What is the role of the ED in the global view of public health? A
patients visit to the ED is often at the end of a cascade of adverse health events,
many of which are preventable. Regular visits to primary care could mitigate the
number of patients presenting to the ED for uncontrolled diabetes, hypertension,
obesity, and hyperlipidemia. ED physicians regularly treat patients with sexually
transmitted diseases, prenatal, and perinatal problems, which could more easily
be addressed at ambulatory clinics. Coronary artery and neurovascular disease
is related to lifestyle and smoking, as well as genetics, and national education
campaigns have been helpful to educate the public. The incidence of cancer is
increasing; often a new diagnosis of cancer is made by the ED physician in their
evaluation of patients with common complaints. Routine screening for
colorectal, breast, cervical and ovarian cancer, among others, should be
expanded. One example of positive change has been safety improvements in
automobiles such as seatbelts, airbags, dashboards, and frame design. These
changes have prevented death and disability for patients involved in motor
vehicle collisions. The role of alcohol in vehicular trauma is well recognized,
and recent interventions to reduce impaired driving have had limited success.
Trauma patients with serious injuries have the potential to consume enormous
ED resources. Intubation, chest tubes, fracture management, and wound care
performed in the ED often takes hours to complete. Imagine how cation and
crowded our EDs would be without these improvements?

CONCLUSION

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 Individual hospitals need to have full capacity protocols, with agreed and
defined triggers. These protocols recruit support from in-patient services, focus the
minds of bed managers and set clearly defined thresholds and actions. These need
to be developed locally and take account of local resources. Many hospitals struggle
to have enough capacity to deal with surges in emergency department activity.
Flexible scheduling models for emergency department medical and nursing staff
have been proposed, but often these pose problems with job satisfaction and
complicate personal commitments. Emergency physicians and their administrators
face an uphill struggle to engage administrators and clinicians elsewhere in the
hospital to assist with emergency department crowding. Prompt discharging of
patients from wards can be difficult, particularly when patients require medication
to be dispensed from a pharmacy, or specialised transport services. Discharge
lounges, where discharged patients can wait before transfer, help reduce hospital
capacity. Early ward rounds of newly admitted patients help to match bed
availability with demand. Boarding patients on inpatient wards, where a patient is
sent to a full ward, to await a bed, is controversial
While there is a wealth of evidence that patients come to harm in crowded
emergency departments, we were unable to find evidence that boarded patients
come to harm on inpatient wards. This lack of evidence probably reflects that fact
that the studies have not been done, rather than absence of effect. Despite this,
professional bodies have consistently pragmatically endorsed boarding on inpatient
wards. Moving only a few boarded patients from a crowded emergency department
has a minimal effect on inpatient wards but has a marked and beneficial effect on
the emergency department.
Can we afford to continue with the current state of emergency department
crowding? Will the current equilibrium shift? Is there perhaps an administrative
acceptance that there will always be a queue for acute care and that the emergency
department is where that will be? Policy makers and commissioners of emergency
services need to consider emergency department crowding as an unintended
consequence of policies and consider how they can incentivise the whole
emergency healthcare system to function effectively. Emergency department
crowding is an increasingly recognised problem across the world. While the

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evidence is clear of the harms, future work needs to systematically evaluate
interventions and guide evidence-based policy.

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