ED Overcrowding Is Not Just an American Problem

Elizabeth DeVos, MD, a professor of emergency medicine at the University of Florida Health in Jacksonville and director of its global health education programs, had an experience that brought home to her the worldwide extent of overcrowding in emergency departments while visiting Australia two years ago to deliver a lecture. She was running on a treadmill at the hotel’s gym watching the local news.

“The only thing that came up on the screen for the half hour I was running was scenes of the ramping of ambulances and overcrowding in Australia’s emergency departments,” Dr. DeVos recalls. “And that is key, to me, of how much of an important international problem this is, because it is being broadcast on everybody’s local evening news…. Wherever you go in the world, we’re seeing this.”

Emergency department overcrowding, manifested by filled ER bays, overflowing waiting rooms, patients boarding in the department for days because there’s no available bed that can take them, other patients treated in bathrooms or in the back of ambulances, or else parked on gurneys pushed against the wall in ER hallways, is widely reported in the US. However, it is a public health concern in many countries, even though they have very different healthcare systems and funding mechanisms.

In many of these cases, you’ll find ambulance crews juggling ambulance diversion or emergency department closures, biding their time leaning against the wall or else ramping outside the ER, parked in the hospital’s driveway or parking lot because they can’t hand over the patient they are trying to deliver so they can move on to their next emergency out on the streets.

“In the United States, we’re really seeing the brunt of this problem. We see all of these issues,” said Dr. DeVos, who practices emergency medicine in a safety net setting. She also chairs the American College of Emergency Medicine’s International Committee. She sits on the Executive Board of the International Federation for Emergency Medicine (IFEM/https://www.ifem.cc/). This organization brings together national and regional societies of emergency physicians to work together to improve the delivery of emergency care worldwide.

In 2022  IFEM released a report from its Access Block Taskforce, calling the problem in emergency departments “pervasive, massive in scale, and amounting to a public health emergency with potentially lethal consequences.”FN1 Of 41 IFEM member countries surveyed in November 2022, 100% reported overcrowding in their emergency departments.

Other countries may have different reasons for their overcrowding problem, Dr. DeVos says. “Yet we’re all seeing overcrowding, and what we call access block,” which is patients in the ED who require inpatient care but can’t gain access to a bed within a reasonable time frame. “It’s definitely affecting our prehospital care colleagues, as well.”

Underlying Causes

What are the underlying reasons for this worldwide problem of overcrowded EDs? Are too many patients making too many ER visits, or is it the demographic tsunami of a growing elderly population, coupled with a lack of mental health treatment alternatives? Is there not enough professional staff to serve ER patients, given the COVID-19 pandemic-induced “Great Retirement” and high rates of burnout shrinking the ED labor force? Or is it massive systemic inefficiencies? Process engineers can point to input, output, and throughput. But these are human beings, not autos on the assembly line.

How does the lack of other avenues for offloading patients to more appropriate settings, such as a hospital bed or a long-term care or psychiatric facility, impact the flow of patients through the ED? What of the growing range and complexity of medical treatments which, if utilized, will add to the time it takes to treat the patient and get test results back? Is the lack of support for primary medical care driving other patients to the ED for what might be considered routine medical needs? In different locales, these issues are present in different combinations.

“You know, for over 15 years, we have identified this as being a major issue for Australia,” says Simon Judkins, MD, emergency physician and director of the emergency department at Echuca Health in Victoria and onetime president of the Australasian College for Emergency Medicine (ACEM/ https://acem.org.au/). ACEM’s first organized national summit on emergency department access blocks was held in 2008.

“We’ve developed papers about overcrowded emergency departments, the inability to get patients admitted to the wards, and their associations with increased morbidity and mortality,” Dr. Judkins says. “We recognize they’re being cared for in a very stressed environment.” Meanwhile, ambulance ramping is definitely getting worse across the country,FN2 with steady increases since 2017, while Dr. Judkins says overcrowding overall is getting worse.

For Stephen Gourley, MD, director of emergency medicine for Alice Springs Hospital in Australia and current president of ACEM, the problem is a system capacity issue, including patient throughput and efficiency in the provision of hospital care. There has been a nationwide retreat from the availability of long-term care for elders, lack of services for dementia patients, underinvestment in mental health treatment, and a lack of emphasis on prevention, with not enough physician specialists in the care of elder patients or end-of-life care alternatives.

“It’s not an ED problem,” adds Dr. Judkins. “The ED is just the place where the problem lives out day to day. And we’ve always said it’s not the size of the ED that’s the issue. If you have a bigger ED, you’ll just have more people waiting for the same inpatient beds. So for us, it’s the ability to get patients admitted who need to go to the wards, which means the timely discharge of those who are already in the hospital.”

Experience of Other Countries

Halfway around the world, in the United Kingdom, hospital ED corridor care was recently declared a national emergency[Link: https://www.rcn.org.uk/news-and-events/Press-Releases/nursing-union-declares-national-emergency-over-corridor-care-crisis], with wait times surging and deaths linked to emergency delays. More than 1.5 million people waited more than 12 hours in the emergency department to get admitted to UK hospitals in 2023.

Italian emergency physician Daniele Coen retired from practice at Niguarda Hospital in Milan in 2016. But he continues to study, think, and write about the issues of emergency medicine.FN3  He recently finished a book about his experience working in the emergency department, due to be published in Italy in October.

Italy’s emergency department overcrowding is similar to other countries’, despite differences in how the system is organized, he says. (Italy has universal health coverage.) “We have tried most of the things you have tried in the US. We’ve tried admission rooms, and discharge rooms for the people we know are going to be discharged but we haven’t finished their paperwork.” Some patients are referred to fast-track pathways. But that hasn’t gotten very far in addressing overcrowding overall.

“Probably there are general aspects which are common to all of us, including an aging population.” But Italy’s average length of hospital stay per patient is longer, while the number of hospital beds has been reduced by almost a third in recent years. That reduction was done with the idea that out-of-hospital care would increase, which didn’t happen, Dr. Coen says. “If we were more efficient with our hospital care, a lower number of beds would be okay, but we’re not efficient.”

Early in Dr. Coen’s career, it was common to admit into the hospital 23 to 24 percent of patients who presented to the emergency department. Now, with improved technology and treatment, only about half as many are admitted to the hospital. That is good for the patient and a relief for the hospital and health system, he says. But it means longer treatment times to provide their care in the ER, contributing to the backlog. But does Dr. Coen feel professional emergency staffing is insufficient? “Always.”

Falling Onto the Trolley

In Ireland, a January 2024, letter from specialist trainees in emergency medicine to the national Health Information and Quality Authority highlighted “continuing and unacceptable overcrowding in the country’s EDs, with associated risks for both patients and staff.” It echoes previous statements from Ireland’s Association of Emergency Medicine, which has called the Irish government’s response to the crisis “disappointing.” There’s even a daily national report on urgent emergency care in the country, called the TrolleyGAR report, which counts how many people admitted to the hospital are still held on “trolleys” (or gurneys) in an emergency department or experiencing other delays in service.

For Mick Molloy, MD, an Irish emergency doctor who works at a small community hospital, Wexford General Hospital, the issue was brought home to him dramatically in May of 2023, during a Bank Holiday weekend, when he suffered a sudden condition that made walking difficult. Dr. Molloy, who is diabetic, experienced temporary paralysis and loss of feeling that left him unable to move his legs, which was later diagnosed as Guillain-Barre syndrome. When he somehow drove himself to the local emergency room, and then to a second facility that had a neurologist on duty, he was made to wait for nearly four days on an ambulance trolley in the emergency department before finally getting to a hospital bed.

He said his time spent on the trolley, while traumatic, is not unusual for Irish patients today. But it was torture for him, being unable to sleep. A police officer and patient detainee who were scuffling on the other side of a thin curtain ended up falling on top of him on his trolley. “I got the medical treatment I needed, but I couldn’t get off that trolley. I sent messages to my doctor friends, but they said there were no beds—they were all filled.” Dr. Molloy did radio and television news interviews about his boarding experience from his place on the trolley.FN4  

“My message to emergency department doctors, based on my experience, is that we have to be more human to our patients in the ED. If you walk by people in the hallway, ask how they are doing and listen to their 30-second reply,” Dr. Molloy says. Patients should get food appropriate to their needs, such as his own diabetic and post-bariatric diet. Even a daily glass of beer wouldn’t hurt most of them. “Another thing, look at the blanket situation. These corridors are cold.”

Dr. Molloy says ED overcrowding in Ireland is likely to get worse before it gets better, as demand for service keeps going up from an aging population and a large European immigrant population without connections to primary care physicians. “Just do the math.”

References

1. Emergency Department Crowding and Access Block in the COVID Era and Beyond. Published by the International Federation for Emergency Medicine on April 22, 2022. https://www.ifem.cc/emergency_department_crowding_and_access_block_in_the_covid_era_and_beyond_webinar_launch_of_the_ifem_taskforce_report.
2. Karnon J, Partington A. Ambulance ramping is getting worse in Australia. Here’s why – and what we can do about it. The Conversation; July 4, 2024. https://theconversation.com/ambulance-ramping-is-getting-worse-in-australia-heres-why-and-what-we-can-do-about-it-232720
3. Coen D. Facing overcrowding in the emergency departments. Intern Emerg Med. 2024 Mar; 19(2):271-272. DOI: 10.1007/s1739-023-03495-2 Epub 2024 Mar 5.
4. Quann J. 'Absolutely scandalous' - Doctor waited three days on hospital trolley for 'life-altering diagnosis'. Newstalk. May 3, 2023. https://www.newstalk.com/news/absolutely-scandalous-doctor-waited-three-days-on-hospital-trolley-for-life-altering-diagnosis-1461617 .

Editor’s Note: What are some creative and successful responses to ED overcrowding being tried in other countries? Look for our follow-up report in the coming weeks.