SPECIAL CONTRIBUTION overcrowding
Critical Decision Making: Managing the Emergency Department in an Overcrowded Hospital Hospital and emergency department overcrowding is a serious and growing problem nationwide. Although EDs are organized around the goals of rapid patient assessment, stabilization, and prompt admission to the hospital, an increasing number are being required to hold admitted floor and critical care patients for extended periods due to lack of vacant inpatient beds. Provision of acceptable patient care under such circumstances requires a fundamental reordering of ED priorities and procedures. Overcrowding is the result of inadequate funding for emergency health care services during a period of increasing demand. The initial focus of management strategies to resolve this problem is the inpatient area and includes evaluation of length of stay, "intent to discharge" policies, flexible bed designations, restriction of in-house transfers, and the use of "overcensus beds." If in-hospital management strategies fail, modifications in ED management may include staffing contingency plans, definition of physician responsibility, inpatient charts, revised pharmacy formulary, new floor plans, and modified accounting systems. Successful resolution of hospital and ED overcrowding m a y be the greatest challenge facing emergency medicine today. [Lynn SG, Kellermann AL: Critical decision making: Managing the emergency department in an overcrowded hospital. Ann Emerg Med March 1991;20:287-292.] /
INTRODUCTION Hospital overcrowding and the resultant congestion due to holding of patients in emergency departments are becoming increasingly widespread. In many communities, overcrowding is severely limiting the public's access to timely emergency medical care and is compromising the quality of care. 1 Because hospital overcrowding frequently requires emergency physicians and nurses to provide inpatient and critical care for extended periods, fundamental changes in ED policies, procedures, and practice style may be needed to facilitate that care.
Stephan G Lynn, MD, FACEP* New York, New York Arthur L Kellermann, MD, MPH¢ Memphis, Tennessee From the Department of Emergency Medicine, St Luke's/Roosevelt Hospital Center, New York, New York;* and the Division of Emergency Medicine, Department of Medicine, University of Tennessee, Memphis.t Received for publication April 23, 1990. Revision received July 27, 1990. Accepted for publication July 31, 1990. Presented at the American College of Emergency Physicians Winter Symposium in Tucson, Arizona, March 1990. Address for reprints: Stephan G Lynn, MD, FACER Department of Emergency Medicine, St Luke's/Roosevelt Hospital Center, 428 West 59th Street, New York, New York 10019.
OVERCROWDING Overcrowding occurs when admitted ED patients cannot leave the department because all staffed inpatient and ICU beds in the hospital are occupied and no beds are available in neighboring facilities for transfer. When ED overcrowding exists, emergency patients who are hospitalized must be held in the ED until a bed becomes available. Patients may wait in the ED several hours for admission; some have waited for days. In large metropolitan areas, ED overload can develop despite the availability of staffed beds because additional patients are being diverted from other overcrowded facilities. When a large percentage of a community's EDs simultaneously adopt "ambulance diversion," "standby," or some other limited availability status, remaining EDs may become overwhelmed with patients, z This set of circumstances can rapidly lead to "ED gridlock" - a particularly dangerous situation in which no ED in the immediate vicinity can safely accommodate additional ambulance patients. The essence of the problem is simple - there are too many patients requiring acute inpatient care and too few beds or hospitals available to care for these patients.
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SCOPE OF THE PROBLEM In 1989, the American College of Emergency Physicians conducted a survey of its chapters to assess the extent of ED and hospital overcrowding nationwide. Each ehapter was asked whether its members had experienced overcrowding as defined above and to what causes it attributed this problem; all 54 chapters responded. ACEP chapters from 41 states (representing 94% of the population) reported overcrowding; all four nonstate chapters (District of Columbia, Puerto Rico, Ontario, and Government Services) reported overcrowding as well. Only nine state chapters reported no problem with overcrowding (Idaho, Minnesota, Nebraska, New Hampshire, New Mexico, North Dakota, Oregon, Utah, and Wyoming). 1 During its 1989 Scientific Assembly, the Emergency Nurses Association polled its state councilors; all 50 state councilors reported overcrowding. 3 At the October 1989 ACEP conference on overcrowding, the University of Tennessee and the National Public Health and Hospital Institute released preliminary results of a survey of National Association of Public Hospitals and Council of Teaching Hospitals member institutions. Results were based on replies from 277 hospitals in 43 states, a 57% reply rate. The report revealed the following. First, private hospitals reported mean o c c u p a n c y rates as high as those noted in public hospitals. Second, three of four responding institutions reported increased rates of ED use during the past three years. Third, during one reference month (August 1988), 40% of reporting hospitals diverted ambulances at least part of the time, and one third were required to transfer patients to other hospitals due to overcrowding. Finally, ED directors at 65% of responding institutions reported that overcrowding was having a moderate-to-severe negative i m p a c t on their quality of care. 4
CONTRIBUTING FACTORS Many factors fuel the problem of ED overcrowding; most are the result of reductions in funding for emergency health care services during a period of increasing demand. Although the relative importance of factors may vary in different commu106/288
nities, respondents to ACEP's survey of its chapters identified the major contributors to the problem of overcrowding 1 as a growing shortage of health care professionals (eg, nurses, especially critical care nurses, and emergency physicians), increased use of EDs as a route of admissions, high inpatient average daily census, hospital bed reductions or conversions to special uses (eg, alcohol or drug detoxification, psychiatry, or rehabilitation), closure of hospitals or EDs, prolonged use of acute care beds by patients who could otherwise be accommodated in nursing homes or at home if resources were available, increasing numbers of poor or uninsured patients, 5 increasing numbers of AIDS patients, and i n c r e a s i n g numbers of drug-related admissions (eg, trauma, overdose, and infectious complications). 6 A l t h o u g h the news media have d o c u m e n t e d major problems with hospital and ED overcrowding in New York, 7 Los Angeles, 8 and other major metropolitan areas, there is growing concern that the problems currently experienced in these cities may represent the future of emergency medicine elsewhere. Because few, if any, of the causes of overc r o w d i n g are easily a m e n a b l e to short-term solutions, it is highly likely this problem will become substantially worse before it gets better.
A MANAGEMENT STRATEGY Most agree that the primary mission of the ED is to provide emergency care and stabilization. Once stabilized, admitted patients should be transported to the appropriate inpatient units in an expeditious manner. When timely transport to an inp a t i e n t u n i t c a n n o t occur, overcrowding may result as admitted patients are held in the ED. Given such circumstances, near-revolutionary changes in ED management may be necessary to maintain adequate care under increasingly adverse circumstances. Initially, measures to deal with overcrowding should focus on recognizing an impending crisis as soon as possible so procedures can be initiated to increase the efficiency and capacity of the hospital's inpatient units. Changes in ED management should be implemented only if these measures fail. If the problem is particularly severe, changes in the proviAnnals of Emergency Medicine
sion of quired, only as step in low. 9
prehospital care may be rebut these must be invoked a last resort. Details of each this management plan fol-
Document the Scope of the Problem Adequate d o c u m e n t a t i o n of the level of ED overcrowding is essential; then, summary statistics can be generated that will be helpful in understanding the effect of various factors on the scope and magnitude of the problem. These data may also be helpful in convincing hospital administrators to lend their efforts to make the changes necessary to improve the quality of ED patient care. Two frequently used ED statistical and management tools may be easily adapted to facilitate i n f o r m a t i o n gathering - the log of admitted patients and the change-of-shift ED patient census report. The ED admissions log should include patient name and medical record number, admission diagnosis, bed type required (eg, medical and surgical, pediatric, obstetrics and gynecology, psychiatry, isolation, ICU, or cardiac care unit; private or service status; and hospital floor), times (eg, ED entry and registration, initiation of physician evaluation, admission decision and bed requested, bed assigned, bed available, nursing report received by floor, and patient transported to floor), comments (special circumstances), end-of-day summary (eg, total ED admissions and total for each bed category, t o t a l "boarder hours" - from admission decision to transport time - and total for each bed category, total admissions to hospital from all sources available from admissions office and percentage of all hospital admissions through the ED), and end-ofmonth summary. To create and record a "snapshot" of the ED, a change-of-shift report can be maintained to document the number and status of all ED patients at fixed times during the day. Whenever physicians or nurses change shift, the information to be recorded should include diversion status, location (include corridor and nondesignated areas), patient name, working diagnosis, status (eg, whether admitted, w h a t service and bed type, whether in evaluation, and whether waiting to be seen), time of ED regis20:3 March 1991
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tration and triage, and summary data (eg, total admitted patients "boarding" in the ED; total patients in the ED; total patients in and awaiting triage; total triaged in waiting room or not yet seen by physician; and total patients in ED, triage, and waiting room). From the above data, one can extract the s u m m a r y statistics and trends for admitted patients waiting (eg, per day, per shift, on average, per month, and so on), average time from registration to physician evaluation for various categories, and average time from admission to transport to floor (eg, per day, per shift, and per bed category). Correlations then can be made between the inpatient daily census and the total number of patients waiting and time waited for admission, total patients in waiting room or not yet seen, total patients who walk out before being seen, and total patient or family complaints. In addition to serving as useful quality assurance data, these statistics may provide justification for the inpatient m a n a g e m e n t procedures and changes in ED and prehospital management, as outlined below.
Inpatient Measures to Deal With Overcrowding Having documented the presence of overcrowding, the next step is to work with hospital administrators, nurses, and inpatient physicians to maximize the hospital's ability to accept additional ED patients in an expeditious manner. The ultimate goal of the institution must be to reverse hospital overcrowding and prevent ED backup. The critical inpatient census level that triggers ED backup must be established. Once this is determined and r e a c h e d , c o n t i n g e n c y p l a n s should be implemented to improve operating efficiency, increase inpatient bed capacity, and restore the flexibility necessary to accommodate ED admissions. All concerned must agree on the parameters that will result in the automatic activation of these contingency plans and/or the meeting of a special bed management committee. To activate their plans, many hospitals have chosen as trigger points total hospital census of more than 85%, lo medical and surgical census of more than 90%; and critical care having no bed or only 20:3 March 1991
one bed available. This bed management committee should have definitive and broad dec i s i o n - m a k i n g capability, s h o u l d meet on a regular basis long before the crisis develops, and should establish contingency plans to be activated automatically whenever indicated. In addition to emergency measures, any hospital with chronically high levels of occupancy should consider adopting most or all of the following options to enhance the efficiency of their inpatient units. Because the majority of these actions are standard management practices and should result in a better quality of care as well as a better hospital financial bottom line, their active pursuit will almost always be productive.
PRIMARY MANAGEMENT STRATEGIES Examine Prolonged Length of Stay The c o m m i t t e e should evaluate the hospital's average length of stay bY diagnosis, physician, and department. Statistics found to be at variance with accepted norms should be referred to the appropriate body of the organized medical staff.
Implement an "Intent to Discharge" Policy W h e n e v e r possible, p h y s i c i a n s should notify the admissions office of their intent to discharge inpatients not later than the evening before discharge; this will allow more time for discharge planning and teaching as well as facilitate early departure from the hospital.
Require Prompt Notification of Patient Discharge by the Inpatient Units The admissions office must be notified as soon as a discharged patient leaves the floor. Some believe that the responsibility for prolonged care of admitted patients in the ED encourages ED staff to advocate the prompt admission and transport of their patients. Conversely, on the inpatient unit, the work and responsibility increment caused by the arrival of a new admission may create a disincentive to the prompt turnover of inpatient beds. Monitoring may be necessary to detect delayed notice of bed availability. Annals of Emergency Medicine
Develop Discharge Lounges Special areas or units can be made available to provide interim care for discharged patients after the discharge time (usually 10:00 AM) has passed. This discharge area can be spaces on each inpatient floor where nursing responsibility remains that of the o r i g i n a l l y a s s i g n e d floor nurses, or it can be a consolidated single location within the hospital where professional supervision is assigned or is already available.
Assign Priority to Elective and Emergency Admissions There should be a pre-established policy defining the priority of bed availability for patients awaiting hospital admission. 11 Depending on the nature of the patient's problems, urgent elective cases may need a priority similar to that of emergency patients. All must agree on a policy that establishes when admission of patients scheduled for n o n u r g e n t elective admissions or for elective invasive procedures may be delayed or deferred. In some cases, the incentive to avoid activation of this policy may be sufficient to encourage compliance with other, less-difficult crisis management tools.
Ensure Flexible Bed Designations Hospital policy should guarantee the maximal possible bed flexibility at times of high census. Beds that otherwise serve limited roles but are equipped and staffed to provide a broader range of care (eg, medical, surgical, subspecialty, private, research, male, female, and so on) must be interchangeable: 12
Aggressively Pursue Dispositions for Alternate Level of Care Patients Frequently, patients occupy acute inpatient beds when all concerned agree that n u r s i n g h o m e care or home care would be more appropriate than continued acute care. The social work department within the hospital or appropriate communitybased agencies, home care nursing agencies, and legal advocates must work together to secure rapid placement to provide more beds for acute inpatient care. 289/107
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Appoint an Admissions Coordinator A supervisor familiar with the admissions office, inpatient and housekeeping procedures, and hospital staff should be assigned on-site responsibility for identification of vacant beds, their efficient turnover, and their timely occupancy by newly admitted patients. If properly devised and aggressively pursued, these procedures will substantially improve the efficiency of hospital operations and may avert serious overcrowding. Should these measures prove inadequate to avoid a crisis, more radical steps should be considered on a contingency basis.
Restrict In-House Transfers A floor-to-floor transfer involves the work and time equal to both a patient discharge and a new hospital admission. During periods of limited bed availability, transfers should be made only for urgent clinical needs.
Appoint a Physician-Admissions Office Liaison A physician may be assigned to work closely with the admissions office to evaluate patients awaiting admission in the ED and patients with urgent illness who are waiting at home. In a crisis, priority access to inpatient beds must be based strictly on medical need.
Define and Staff Overcensus Beds To the extent allowed by local laws and regulations, additional admitted patient care locations should be defined in areas other than the ED. Many nontraditional inpatient locations can permit reasonable medical and nursing care with more of the " a m e n i t i e s " of inpatient care than can otherwise be provided in the ED. Distribution of "ED boarder" patients throughout all appropriate inpatient units may be more desirable from nursing and patient perspectives. Sending ten patients to ten different 20-bed units will require each nursing team to exceed their capacity by 5%. Retaining all ten patients in the ED may require the ED nursing staff to exceed their normal maximal patient care capacity by 50% to 100%. Contingency plans may include a process for the approval of additional staff to reopen units that have been 108/290
temporarily closed; adding beds to existing rooms (ie, one additional bed to large, private rooms); redefining room function (eg, some inpatient waiting rooms, conference rooms, solaria, and so on may be capable of accommodating patients); and using corridor beds (placement of temporary beds or even ED stretchers in inpatient corridors frequently will provide a better milieu for inpatient care than the crowded, busy, and noisy corridor of an active ED). 11
Implement a "30-Minute Rule" In some hospitals in which bed assignment is followed by a prolonged period during w h i c h the room is cleaned and the bed is prepared for the next admission, the ED has the option of sending an admitted pat i e n t to their assigned floor bed within 30 minutes of the time of assignment by the admissions office, even if the bed is not yet ready. This provides a powerful incentive for the efficient turnover of a vacated bed. Only a nursing supervisor can intervene and request that the patient remain in the ED.
Develop a Holding Unit In hospitals in which the holding of admitted patients in the ED has become an everyday phenomenon, space and staff have been allocated to provide interim inpatient care for patients who would otherwise wait in the ED for a prolonged period. In many cases, the location and staff responsibility are separate from those of the EDJ3
MANAGEMENT IN THE CRITICALLY OVERCROWDED ED If in-hospital management strategies fail to provide the beds needed for admitted patients waiting in the ED, substantive modifications in ED management and practice patterns may be required to preserve an acceptable standard of care in the ED. Most of these changes will facilitate the provision of inpatient care or critical care within the ED long beyond the timeframes for which it has previously been expected. In such circumstances, emergency physicians must modify to the extent possible their policies and procedures to attempt to meet inpatient standards of care. Overcrowding cannot be managed by simply "working harder." BaAnnals of Emergency Medicine
sic changes will be required to maintain an acceptable level of care, for example, fundamental changes in the underlying goals, mission, and philosophy of EDs. This re-evaluation should include the following management points.
Develop Contingency Plans for Supplemental ED Staffing The ED should establish explicit criteria that define when additional professional staff (nurses, physicians, or both) must be called in to reinforce existing ED staff. To share patient care responsibilities equally and avoid burnout of ED personnel, it must be understood that before allocation of additional staff to the ED, staff should also be added to inpatient units or ICUs to provide enough personnel to accommodate existing ED boarders. Furthermore, appropriate inpatient or ICU staff-to-patient ratios (eg, two patients to one ICU nurse) should not prevent the transfer of ED patients to inpatient or ICU units when the same staffing ratios and standards of patient care cannot be maintained in the ED. Maximal flexibility will always be required. The bottom line must be the best possible patient care for the greatest number of patients.
Define Physician Responsibility for ED Boarders There must be a clear understanding as to which physician has responsibility for writing orders and for providing routine ongoing care and consultation for admitted patients who board in the ED. 11 Most directors of EDs, in consultation with their inpatient medical staff colleagues, assign this responsibility to a physician who routinely provides such inpatient care (the patient's private physician, a houseofficer, or a physician assigned by the service to which the patient is admitted). Emergency physicians should agree to provide emergency care whenever it becomes necessary for as long as the patient remains within the confines of the ED. If o v e r c r o w d i n g results in the backup of a significant number of admitted patients in the ED, incremental emergency physician staffing may be required. The well-documented order of an i n p a t i e n t p h y s i c i a n should also be required to discharge patients from the ED once the pa20:3 March 1991
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tient has been admitted, even if the patient has never left the ED.
Generate and Maintain Standard Inpatient Charts As a direct corollary to the above, many overcrowded EDs now create complete inpatient charts (binders, physicians' orders, history and physical examination, progress notes at a regular frequency, and ancillary reports).
Allocate Additional ED Staff The decision to support prolonged inpatient or ICU care in the ED will require additional nursing support and staff. Some hospitals have successfully trained nursing aides who report to the ED nursing staff to perform phlebotomy and ECGs. The dietary department will also need to modify its approach to the ED and consider the ED as a source of frequent inpatient meal requests. Orders for complicated ancillary tests (eg, exercise tolerance tests, radionuclide cardiac scans), in-house consultations not frequently ordered in the ED, or administration of medications on a scheduled basis (eg, penicillin IV every four hours) will require clerical transcription of orders, scheduling of routine tests for ED patients, and adoption of nursing systems for inpatient care.
Expand ED Pharmacy Formularies ED medication stores must include pharmaceuticals not regularly used in the ED (eg, c h e m o t h e r a p e u t i c agents).
Revise ED Floor Plans ED floor plans should be expanded to include the formal designation of hallway spaces or other nonstandard patient care areas so that all staff can locate all patients quickly. Such locations should be planned carefully to provide the best access to care while providing the maximal degree of privacy available.
vidual needs of both the staff and patients during prolonged periods of ED overcrowding.
Revise Accounting Systems H o s p i t a l - b a s e d cost a c c o u n t i n g systems must do their best to define the difference between admitted patients who dwell in the ED for prolonged periods and routine ED discharges. The attribution of substantial costs for inpatient pharmaceuticals and ancillaries to the ED without acknowledging ED responsibility for inpatient revenue will create a substantial negative change in the ED's apparent financial bottom line. It is therefore advisable to modify both the hospital and the physician billing systems to establish appropriate fees and mechanisms for billing admitted patients who board in the ED for prolonged periods.
CRISIS MANAGEMENT OF THE EMERGENCY MEDICAL SERVICES SYSTEM When o v e r c r o w d i n g s i m u l t a n e ously involves several EDs in a community, the prehospital care system may become severely compromised. When many hospitals request ambulance diversion or "drive-by" status, ambulance transport times will be prolonged and definitive care delayed. Management of this aspect of h o s p i t a l o v e r c r o w d i n g a n d ED backup requires substantial interhospital cooperation and is usually dependent on the existence of a welldefined emergency medical services (EMS) system with integrated centralized dispatch of ambulances and strong medical direction. EMS systems and hospital EDs must share policies, protocols, and information to define a consistent threshold for ambulance diversion and to f a c i l i t a t e the s u b s e q u e n t transfer of patients. The basis of many such systems is an information pool shared by all hospitals, EDs, and the EMS system.
Diversion Protocols Provide Personal Support for Patients and Staff The level of stress for both patients and staff is heightened during periods of ED backup. A cadre of patient representatives and advocates, social workers, chaplains, volunteers, and other caring professionals may be a valuable addition to meet the indi20:3 March 1991
All protocols and criteria must be mutually agreed on, and the system of medical direction must be well defined. ~ Consistent criteria for diversion (eg, number of admitted patients waiting for beds, number of monitored patients awaiting admission, or number of available monitors or stretchers) are required. These criteAnnals of Emergency Medicine
ria should be easily understood, verifiable, and consistently applied. It should be required that each hospital requesting diversion c o m m u n i c a t e this request to EMS on a regular basis; it is frequently most convenient to agree that unless specified, diversion will continue until the end of t h e s h i f t ( u s u a l l y 8 : 0 0 A M , 4"00 PM, or 12:00 midnight) and will automatically expire at the end of shift, unless it is requested and documented again. In most cases, EMS supervisory staff should be encouraged to visit hospital EDs when a predefined number of EDs in subregions ( n e i g h b o r h o o d s or m e t r o p o l i t a n areas) request diversion simultaneously. 14 Medical direction should determine when or if the severity of the illness or injury, the specialized nature of the disease state, or even patient or physician preference will be allowed to override an ED request for closure; the hospital and its staff's responsibility or obligation in accepting such patients while on diversion or standby must be clearly defined as well. All disputes as to the appropriateness or validity of such an override of diversion must be resolved only after the patient has been received and evaluated by a staff physician.
Transfer Protocols Perhaps the most important step in dealing with recurrent overcrowding is the establishment of a mutually agreed-on system to facilitate interhospital transfer of patients. In the present era, in which federal legislation requires that the circumstances, indications, stability, and interhospital transfer of patient care responsibility be documented appropriately, such pre-existent agreements and the sharing of information may become particularly important. Hospitals, hospital associations, and EMS systems have cooperated to produce manuals to facilitate such transfers. In these documents, each hospital defines total bed capacity, special bed capacity (medical and surgical, pediatric, obstetrics and gynecology, psychiatry, drug and alcohol, rehabilitation, ICU, cardiac care unit, burn, trauma care, and other specialty types), person or title to contact for administrative and medical approval for transfer (per bed category, if appropriate), and transfer 291/109
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phone number (specific for time of day and day of week, per bed category, if appropriate). ~s Such manuals have substantially facilitated the interhospital transfer of patients. CONCLUSION The development of realistic and effective contingency plans will all o w e m e r g e n c y p h y s i c i a n s and nurses to join their inpatient colleagues, hospital administrators, prehospital providers, and EMS system managers in dealing with the immediate consequences of overcrowding. These m a n a g e m e n t tools are more than simple coping m e c h a n i s m s ; however, few will produce significant long-term changes in the nature of h o s p i t a l o v e r c r o w d i n g and t~D backup. EDs provide a critically important safety net for our nation's health care system. Unfortunately, our current capacity to meet the needs of our patients is being stretched to the breaking point. Long-term resolution of the problem of hospital and ED overcrowding will require a substantial c o m m i t m e n t of societal resources
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and vision. Successful resolution of this problem will be a monumental task. It is, perhaps, the greatest challenge facing emergency medicine today. The authors acknowledge the contributions of the fellow members of the ACEP Task Force on Hospital and ED Overcrowding: Robert Hockberger, MD, FACEP; E Jackson Allison, MD, FACEP; Charlotte Yeh, MD, FACEP; and Marion Wiseman, ACEP staff. They are also indebted to Maureen Woods Spahr and Carol Conway for their assistance with the preparation of this manuscript.
REFERENCES 1. Lynn SG, Hockberger RS, Kellermann A, et al: A Re port From the American College of Emergency Physicians Task Force on Hospital Overcrowding and Emer gency Department Overload. Dallas, ACEP, September 1989. 2. Patient Overload and Ambulance Diversion Re port and Recommendations of the EMS Task Force. Burlington, Massachusetts Hospital Association, 1988.
3. Fadale J: The Emergency Nurse Perspective. N e w York, ACEP Overcrowding Conference, October 13, 1989. 4. Kellermann A: The National Association of Public Hospitals. New York, ACEP Overcrowding Conference, October 13, 1989.
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5. Gallagher JE, Lynn SG: The etiology of medical gridlock: Causes of emergency department overcrowding in New York City. J Emerg Med 1990;8:785-790. 6. Kotelchnck R: Down and out in the "new Calcutta": New York City's health care crisis. Health/PAC Bulletin 1989;19:4-10. 7. French HW: The poor overwhelm hospitals in New York as they seek care. The Sunday New York Times, December 4, 1988, p L 8. Waters T: In poor health - Some South Bay hospitals struggle to maintain services while caring for the indigent, uninsured. Los Angeles Times, Sunday, May 14, 1989, part II, B:6ft. 9. Lynn SG, Allison EJ, Kellermann A, Yeh, C: Managing the emergency department overloaded with inpatient and ICU boarders, in Comprehensive Guide to Effective Practice Management, ed 2. Dallas, American College of Emergency Physicians, 1991, in press. i0. Storer RH, Hancock WM: A Simulation Study of Parameters Affecting Hospital Unit Occupancy and Implications for Unit Sizing. Ann Arbor, Michigan, University of Michigan, 1976. 11. Sweeney RD: Dear hospital administrator (letter). New York, Office of Health Systems Management, New York Department of Health, December 2, 1988. 12. Sweeney RD: Dear administrator (letter). New York, Office of Health Systems Management, New York Department of Health, January 19, 1990. 13. American College of Emergency Physicians: Emergency department observation units. Ann Emerg Med 1988;17:95-96. 14. A Full House - Hospital Diversion Guiddines: Rec ommendation of the ConnciI of Planning, Committee on EMS. New Jersey Hospital Association, 1990. 15. Dorman HG: Transfer Liaison Resource Book. Mas sachusetts Hospital Association, 1989.
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Critical Decision Making: Managing the Emergency Department in an Overcrowded Hospital Hospital and emergency department overcrowding is a serious and growing problem nationwide. Although EDs are organized around the goals of rapid patient assessment, stabilization, and prompt admission to the hospital, an increasing number are being required to hold admitted floor and critical care patients for extended periods due to lack of vacant inpatient beds. Provision of acceptable patient care under such circumstances requires a fundamental reordering of ED priorities and procedures. Overcrowding is the result of inadequate funding for emergency health care services during a period of increasing demand. The initial focus of management strategies to resolve this problem is the inpatient area and includes evaluation of length of stay, "intent to discharge" policies, flexible bed designations, restriction of in-house transfers, and the use of "overcensus beds." If in-hospital management strategies fail, modifications in ED management may include staffing contingency plans, definition of physician responsibility, inpatient charts, revised pharmacy formulary, new floor plans, and modified accounting systems. Successful resolution of hospital and ED overcrowding m a y be the greatest challenge facing emergency medicine today. [Lynn SG, Kellermann AL: Critical decision making: Managing the emergency department in an overcrowded hospital. Ann Emerg Med March 1991;20:287-292.] /
INTRODUCTION Hospital overcrowding and the resultant congestion due to holding of patients in emergency departments are becoming increasingly widespread. In many communities, overcrowding is severely limiting the public's access to timely emergency medical care and is compromising the quality of care. 1 Because hospital overcrowding frequently requires emergency physicians and nurses to provide inpatient and critical care for extended periods, fundamental changes in ED policies, procedures, and practice style may be needed to facilitate that care.
Stephan G Lynn, MD, FACEP* New York, New York Arthur L Kellermann, MD, MPH¢ Memphis, Tennessee From the Department of Emergency Medicine, St Luke's/Roosevelt Hospital Center, New York, New York;* and the Division of Emergency Medicine, Department of Medicine, University of Tennessee, Memphis.t Received for publication April 23, 1990. Revision received July 27, 1990. Accepted for publication July 31, 1990. Presented at the American College of Emergency Physicians Winter Symposium in Tucson, Arizona, March 1990. Address for reprints: Stephan G Lynn, MD, FACER Department of Emergency Medicine, St Luke's/Roosevelt Hospital Center, 428 West 59th Street, New York, New York 10019.
OVERCROWDING Overcrowding occurs when admitted ED patients cannot leave the department because all staffed inpatient and ICU beds in the hospital are occupied and no beds are available in neighboring facilities for transfer. When ED overcrowding exists, emergency patients who are hospitalized must be held in the ED until a bed becomes available. Patients may wait in the ED several hours for admission; some have waited for days. In large metropolitan areas, ED overload can develop despite the availability of staffed beds because additional patients are being diverted from other overcrowded facilities. When a large percentage of a community's EDs simultaneously adopt "ambulance diversion," "standby," or some other limited availability status, remaining EDs may become overwhelmed with patients, z This set of circumstances can rapidly lead to "ED gridlock" - a particularly dangerous situation in which no ED in the immediate vicinity can safely accommodate additional ambulance patients. The essence of the problem is simple - there are too many patients requiring acute inpatient care and too few beds or hospitals available to care for these patients.
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SCOPE OF THE PROBLEM In 1989, the American College of Emergency Physicians conducted a survey of its chapters to assess the extent of ED and hospital overcrowding nationwide. Each ehapter was asked whether its members had experienced overcrowding as defined above and to what causes it attributed this problem; all 54 chapters responded. ACEP chapters from 41 states (representing 94% of the population) reported overcrowding; all four nonstate chapters (District of Columbia, Puerto Rico, Ontario, and Government Services) reported overcrowding as well. Only nine state chapters reported no problem with overcrowding (Idaho, Minnesota, Nebraska, New Hampshire, New Mexico, North Dakota, Oregon, Utah, and Wyoming). 1 During its 1989 Scientific Assembly, the Emergency Nurses Association polled its state councilors; all 50 state councilors reported overcrowding. 3 At the October 1989 ACEP conference on overcrowding, the University of Tennessee and the National Public Health and Hospital Institute released preliminary results of a survey of National Association of Public Hospitals and Council of Teaching Hospitals member institutions. Results were based on replies from 277 hospitals in 43 states, a 57% reply rate. The report revealed the following. First, private hospitals reported mean o c c u p a n c y rates as high as those noted in public hospitals. Second, three of four responding institutions reported increased rates of ED use during the past three years. Third, during one reference month (August 1988), 40% of reporting hospitals diverted ambulances at least part of the time, and one third were required to transfer patients to other hospitals due to overcrowding. Finally, ED directors at 65% of responding institutions reported that overcrowding was having a moderate-to-severe negative i m p a c t on their quality of care. 4
CONTRIBUTING FACTORS Many factors fuel the problem of ED overcrowding; most are the result of reductions in funding for emergency health care services during a period of increasing demand. Although the relative importance of factors may vary in different commu106/288
nities, respondents to ACEP's survey of its chapters identified the major contributors to the problem of overcrowding 1 as a growing shortage of health care professionals (eg, nurses, especially critical care nurses, and emergency physicians), increased use of EDs as a route of admissions, high inpatient average daily census, hospital bed reductions or conversions to special uses (eg, alcohol or drug detoxification, psychiatry, or rehabilitation), closure of hospitals or EDs, prolonged use of acute care beds by patients who could otherwise be accommodated in nursing homes or at home if resources were available, increasing numbers of poor or uninsured patients, 5 increasing numbers of AIDS patients, and i n c r e a s i n g numbers of drug-related admissions (eg, trauma, overdose, and infectious complications). 6 A l t h o u g h the news media have d o c u m e n t e d major problems with hospital and ED overcrowding in New York, 7 Los Angeles, 8 and other major metropolitan areas, there is growing concern that the problems currently experienced in these cities may represent the future of emergency medicine elsewhere. Because few, if any, of the causes of overc r o w d i n g are easily a m e n a b l e to short-term solutions, it is highly likely this problem will become substantially worse before it gets better.
A MANAGEMENT STRATEGY Most agree that the primary mission of the ED is to provide emergency care and stabilization. Once stabilized, admitted patients should be transported to the appropriate inpatient units in an expeditious manner. When timely transport to an inp a t i e n t u n i t c a n n o t occur, overcrowding may result as admitted patients are held in the ED. Given such circumstances, near-revolutionary changes in ED management may be necessary to maintain adequate care under increasingly adverse circumstances. Initially, measures to deal with overcrowding should focus on recognizing an impending crisis as soon as possible so procedures can be initiated to increase the efficiency and capacity of the hospital's inpatient units. Changes in ED management should be implemented only if these measures fail. If the problem is particularly severe, changes in the proviAnnals of Emergency Medicine
sion of quired, only as step in low. 9
prehospital care may be rebut these must be invoked a last resort. Details of each this management plan fol-
Document the Scope of the Problem Adequate d o c u m e n t a t i o n of the level of ED overcrowding is essential; then, summary statistics can be generated that will be helpful in understanding the effect of various factors on the scope and magnitude of the problem. These data may also be helpful in convincing hospital administrators to lend their efforts to make the changes necessary to improve the quality of ED patient care. Two frequently used ED statistical and management tools may be easily adapted to facilitate i n f o r m a t i o n gathering - the log of admitted patients and the change-of-shift ED patient census report. The ED admissions log should include patient name and medical record number, admission diagnosis, bed type required (eg, medical and surgical, pediatric, obstetrics and gynecology, psychiatry, isolation, ICU, or cardiac care unit; private or service status; and hospital floor), times (eg, ED entry and registration, initiation of physician evaluation, admission decision and bed requested, bed assigned, bed available, nursing report received by floor, and patient transported to floor), comments (special circumstances), end-of-day summary (eg, total ED admissions and total for each bed category, t o t a l "boarder hours" - from admission decision to transport time - and total for each bed category, total admissions to hospital from all sources available from admissions office and percentage of all hospital admissions through the ED), and end-ofmonth summary. To create and record a "snapshot" of the ED, a change-of-shift report can be maintained to document the number and status of all ED patients at fixed times during the day. Whenever physicians or nurses change shift, the information to be recorded should include diversion status, location (include corridor and nondesignated areas), patient name, working diagnosis, status (eg, whether admitted, w h a t service and bed type, whether in evaluation, and whether waiting to be seen), time of ED regis20:3 March 1991
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tration and triage, and summary data (eg, total admitted patients "boarding" in the ED; total patients in the ED; total patients in and awaiting triage; total triaged in waiting room or not yet seen by physician; and total patients in ED, triage, and waiting room). From the above data, one can extract the s u m m a r y statistics and trends for admitted patients waiting (eg, per day, per shift, on average, per month, and so on), average time from registration to physician evaluation for various categories, and average time from admission to transport to floor (eg, per day, per shift, and per bed category). Correlations then can be made between the inpatient daily census and the total number of patients waiting and time waited for admission, total patients in waiting room or not yet seen, total patients who walk out before being seen, and total patient or family complaints. In addition to serving as useful quality assurance data, these statistics may provide justification for the inpatient m a n a g e m e n t procedures and changes in ED and prehospital management, as outlined below.
Inpatient Measures to Deal With Overcrowding Having documented the presence of overcrowding, the next step is to work with hospital administrators, nurses, and inpatient physicians to maximize the hospital's ability to accept additional ED patients in an expeditious manner. The ultimate goal of the institution must be to reverse hospital overcrowding and prevent ED backup. The critical inpatient census level that triggers ED backup must be established. Once this is determined and r e a c h e d , c o n t i n g e n c y p l a n s should be implemented to improve operating efficiency, increase inpatient bed capacity, and restore the flexibility necessary to accommodate ED admissions. All concerned must agree on the parameters that will result in the automatic activation of these contingency plans and/or the meeting of a special bed management committee. To activate their plans, many hospitals have chosen as trigger points total hospital census of more than 85%, lo medical and surgical census of more than 90%; and critical care having no bed or only 20:3 March 1991
one bed available. This bed management committee should have definitive and broad dec i s i o n - m a k i n g capability, s h o u l d meet on a regular basis long before the crisis develops, and should establish contingency plans to be activated automatically whenever indicated. In addition to emergency measures, any hospital with chronically high levels of occupancy should consider adopting most or all of the following options to enhance the efficiency of their inpatient units. Because the majority of these actions are standard management practices and should result in a better quality of care as well as a better hospital financial bottom line, their active pursuit will almost always be productive.
PRIMARY MANAGEMENT STRATEGIES Examine Prolonged Length of Stay The c o m m i t t e e should evaluate the hospital's average length of stay bY diagnosis, physician, and department. Statistics found to be at variance with accepted norms should be referred to the appropriate body of the organized medical staff.
Implement an "Intent to Discharge" Policy W h e n e v e r possible, p h y s i c i a n s should notify the admissions office of their intent to discharge inpatients not later than the evening before discharge; this will allow more time for discharge planning and teaching as well as facilitate early departure from the hospital.
Require Prompt Notification of Patient Discharge by the Inpatient Units The admissions office must be notified as soon as a discharged patient leaves the floor. Some believe that the responsibility for prolonged care of admitted patients in the ED encourages ED staff to advocate the prompt admission and transport of their patients. Conversely, on the inpatient unit, the work and responsibility increment caused by the arrival of a new admission may create a disincentive to the prompt turnover of inpatient beds. Monitoring may be necessary to detect delayed notice of bed availability. Annals of Emergency Medicine
Develop Discharge Lounges Special areas or units can be made available to provide interim care for discharged patients after the discharge time (usually 10:00 AM) has passed. This discharge area can be spaces on each inpatient floor where nursing responsibility remains that of the o r i g i n a l l y a s s i g n e d floor nurses, or it can be a consolidated single location within the hospital where professional supervision is assigned or is already available.
Assign Priority to Elective and Emergency Admissions There should be a pre-established policy defining the priority of bed availability for patients awaiting hospital admission. 11 Depending on the nature of the patient's problems, urgent elective cases may need a priority similar to that of emergency patients. All must agree on a policy that establishes when admission of patients scheduled for n o n u r g e n t elective admissions or for elective invasive procedures may be delayed or deferred. In some cases, the incentive to avoid activation of this policy may be sufficient to encourage compliance with other, less-difficult crisis management tools.
Ensure Flexible Bed Designations Hospital policy should guarantee the maximal possible bed flexibility at times of high census. Beds that otherwise serve limited roles but are equipped and staffed to provide a broader range of care (eg, medical, surgical, subspecialty, private, research, male, female, and so on) must be interchangeable: 12
Aggressively Pursue Dispositions for Alternate Level of Care Patients Frequently, patients occupy acute inpatient beds when all concerned agree that n u r s i n g h o m e care or home care would be more appropriate than continued acute care. The social work department within the hospital or appropriate communitybased agencies, home care nursing agencies, and legal advocates must work together to secure rapid placement to provide more beds for acute inpatient care. 289/107
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Appoint an Admissions Coordinator A supervisor familiar with the admissions office, inpatient and housekeeping procedures, and hospital staff should be assigned on-site responsibility for identification of vacant beds, their efficient turnover, and their timely occupancy by newly admitted patients. If properly devised and aggressively pursued, these procedures will substantially improve the efficiency of hospital operations and may avert serious overcrowding. Should these measures prove inadequate to avoid a crisis, more radical steps should be considered on a contingency basis.
Restrict In-House Transfers A floor-to-floor transfer involves the work and time equal to both a patient discharge and a new hospital admission. During periods of limited bed availability, transfers should be made only for urgent clinical needs.
Appoint a Physician-Admissions Office Liaison A physician may be assigned to work closely with the admissions office to evaluate patients awaiting admission in the ED and patients with urgent illness who are waiting at home. In a crisis, priority access to inpatient beds must be based strictly on medical need.
Define and Staff Overcensus Beds To the extent allowed by local laws and regulations, additional admitted patient care locations should be defined in areas other than the ED. Many nontraditional inpatient locations can permit reasonable medical and nursing care with more of the " a m e n i t i e s " of inpatient care than can otherwise be provided in the ED. Distribution of "ED boarder" patients throughout all appropriate inpatient units may be more desirable from nursing and patient perspectives. Sending ten patients to ten different 20-bed units will require each nursing team to exceed their capacity by 5%. Retaining all ten patients in the ED may require the ED nursing staff to exceed their normal maximal patient care capacity by 50% to 100%. Contingency plans may include a process for the approval of additional staff to reopen units that have been 108/290
temporarily closed; adding beds to existing rooms (ie, one additional bed to large, private rooms); redefining room function (eg, some inpatient waiting rooms, conference rooms, solaria, and so on may be capable of accommodating patients); and using corridor beds (placement of temporary beds or even ED stretchers in inpatient corridors frequently will provide a better milieu for inpatient care than the crowded, busy, and noisy corridor of an active ED). 11
Implement a "30-Minute Rule" In some hospitals in which bed assignment is followed by a prolonged period during w h i c h the room is cleaned and the bed is prepared for the next admission, the ED has the option of sending an admitted pat i e n t to their assigned floor bed within 30 minutes of the time of assignment by the admissions office, even if the bed is not yet ready. This provides a powerful incentive for the efficient turnover of a vacated bed. Only a nursing supervisor can intervene and request that the patient remain in the ED.
Develop a Holding Unit In hospitals in which the holding of admitted patients in the ED has become an everyday phenomenon, space and staff have been allocated to provide interim inpatient care for patients who would otherwise wait in the ED for a prolonged period. In many cases, the location and staff responsibility are separate from those of the EDJ3
MANAGEMENT IN THE CRITICALLY OVERCROWDED ED If in-hospital management strategies fail to provide the beds needed for admitted patients waiting in the ED, substantive modifications in ED management and practice patterns may be required to preserve an acceptable standard of care in the ED. Most of these changes will facilitate the provision of inpatient care or critical care within the ED long beyond the timeframes for which it has previously been expected. In such circumstances, emergency physicians must modify to the extent possible their policies and procedures to attempt to meet inpatient standards of care. Overcrowding cannot be managed by simply "working harder." BaAnnals of Emergency Medicine
sic changes will be required to maintain an acceptable level of care, for example, fundamental changes in the underlying goals, mission, and philosophy of EDs. This re-evaluation should include the following management points.
Develop Contingency Plans for Supplemental ED Staffing The ED should establish explicit criteria that define when additional professional staff (nurses, physicians, or both) must be called in to reinforce existing ED staff. To share patient care responsibilities equally and avoid burnout of ED personnel, it must be understood that before allocation of additional staff to the ED, staff should also be added to inpatient units or ICUs to provide enough personnel to accommodate existing ED boarders. Furthermore, appropriate inpatient or ICU staff-to-patient ratios (eg, two patients to one ICU nurse) should not prevent the transfer of ED patients to inpatient or ICU units when the same staffing ratios and standards of patient care cannot be maintained in the ED. Maximal flexibility will always be required. The bottom line must be the best possible patient care for the greatest number of patients.
Define Physician Responsibility for ED Boarders There must be a clear understanding as to which physician has responsibility for writing orders and for providing routine ongoing care and consultation for admitted patients who board in the ED. 11 Most directors of EDs, in consultation with their inpatient medical staff colleagues, assign this responsibility to a physician who routinely provides such inpatient care (the patient's private physician, a houseofficer, or a physician assigned by the service to which the patient is admitted). Emergency physicians should agree to provide emergency care whenever it becomes necessary for as long as the patient remains within the confines of the ED. If o v e r c r o w d i n g results in the backup of a significant number of admitted patients in the ED, incremental emergency physician staffing may be required. The well-documented order of an i n p a t i e n t p h y s i c i a n should also be required to discharge patients from the ED once the pa20:3 March 1991
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tient has been admitted, even if the patient has never left the ED.
Generate and Maintain Standard Inpatient Charts As a direct corollary to the above, many overcrowded EDs now create complete inpatient charts (binders, physicians' orders, history and physical examination, progress notes at a regular frequency, and ancillary reports).
Allocate Additional ED Staff The decision to support prolonged inpatient or ICU care in the ED will require additional nursing support and staff. Some hospitals have successfully trained nursing aides who report to the ED nursing staff to perform phlebotomy and ECGs. The dietary department will also need to modify its approach to the ED and consider the ED as a source of frequent inpatient meal requests. Orders for complicated ancillary tests (eg, exercise tolerance tests, radionuclide cardiac scans), in-house consultations not frequently ordered in the ED, or administration of medications on a scheduled basis (eg, penicillin IV every four hours) will require clerical transcription of orders, scheduling of routine tests for ED patients, and adoption of nursing systems for inpatient care.
Expand ED Pharmacy Formularies ED medication stores must include pharmaceuticals not regularly used in the ED (eg, c h e m o t h e r a p e u t i c agents).
Revise ED Floor Plans ED floor plans should be expanded to include the formal designation of hallway spaces or other nonstandard patient care areas so that all staff can locate all patients quickly. Such locations should be planned carefully to provide the best access to care while providing the maximal degree of privacy available.
vidual needs of both the staff and patients during prolonged periods of ED overcrowding.
Revise Accounting Systems H o s p i t a l - b a s e d cost a c c o u n t i n g systems must do their best to define the difference between admitted patients who dwell in the ED for prolonged periods and routine ED discharges. The attribution of substantial costs for inpatient pharmaceuticals and ancillaries to the ED without acknowledging ED responsibility for inpatient revenue will create a substantial negative change in the ED's apparent financial bottom line. It is therefore advisable to modify both the hospital and the physician billing systems to establish appropriate fees and mechanisms for billing admitted patients who board in the ED for prolonged periods.
CRISIS MANAGEMENT OF THE EMERGENCY MEDICAL SERVICES SYSTEM When o v e r c r o w d i n g s i m u l t a n e ously involves several EDs in a community, the prehospital care system may become severely compromised. When many hospitals request ambulance diversion or "drive-by" status, ambulance transport times will be prolonged and definitive care delayed. Management of this aspect of h o s p i t a l o v e r c r o w d i n g a n d ED backup requires substantial interhospital cooperation and is usually dependent on the existence of a welldefined emergency medical services (EMS) system with integrated centralized dispatch of ambulances and strong medical direction. EMS systems and hospital EDs must share policies, protocols, and information to define a consistent threshold for ambulance diversion and to f a c i l i t a t e the s u b s e q u e n t transfer of patients. The basis of many such systems is an information pool shared by all hospitals, EDs, and the EMS system.
Diversion Protocols Provide Personal Support for Patients and Staff The level of stress for both patients and staff is heightened during periods of ED backup. A cadre of patient representatives and advocates, social workers, chaplains, volunteers, and other caring professionals may be a valuable addition to meet the indi20:3 March 1991
All protocols and criteria must be mutually agreed on, and the system of medical direction must be well defined. ~ Consistent criteria for diversion (eg, number of admitted patients waiting for beds, number of monitored patients awaiting admission, or number of available monitors or stretchers) are required. These criteAnnals of Emergency Medicine
ria should be easily understood, verifiable, and consistently applied. It should be required that each hospital requesting diversion c o m m u n i c a t e this request to EMS on a regular basis; it is frequently most convenient to agree that unless specified, diversion will continue until the end of t h e s h i f t ( u s u a l l y 8 : 0 0 A M , 4"00 PM, or 12:00 midnight) and will automatically expire at the end of shift, unless it is requested and documented again. In most cases, EMS supervisory staff should be encouraged to visit hospital EDs when a predefined number of EDs in subregions ( n e i g h b o r h o o d s or m e t r o p o l i t a n areas) request diversion simultaneously. 14 Medical direction should determine when or if the severity of the illness or injury, the specialized nature of the disease state, or even patient or physician preference will be allowed to override an ED request for closure; the hospital and its staff's responsibility or obligation in accepting such patients while on diversion or standby must be clearly defined as well. All disputes as to the appropriateness or validity of such an override of diversion must be resolved only after the patient has been received and evaluated by a staff physician.
Transfer Protocols Perhaps the most important step in dealing with recurrent overcrowding is the establishment of a mutually agreed-on system to facilitate interhospital transfer of patients. In the present era, in which federal legislation requires that the circumstances, indications, stability, and interhospital transfer of patient care responsibility be documented appropriately, such pre-existent agreements and the sharing of information may become particularly important. Hospitals, hospital associations, and EMS systems have cooperated to produce manuals to facilitate such transfers. In these documents, each hospital defines total bed capacity, special bed capacity (medical and surgical, pediatric, obstetrics and gynecology, psychiatry, drug and alcohol, rehabilitation, ICU, cardiac care unit, burn, trauma care, and other specialty types), person or title to contact for administrative and medical approval for transfer (per bed category, if appropriate), and transfer 291/109
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phone number (specific for time of day and day of week, per bed category, if appropriate). ~s Such manuals have substantially facilitated the interhospital transfer of patients. CONCLUSION The development of realistic and effective contingency plans will all o w e m e r g e n c y p h y s i c i a n s and nurses to join their inpatient colleagues, hospital administrators, prehospital providers, and EMS system managers in dealing with the immediate consequences of overcrowding. These m a n a g e m e n t tools are more than simple coping m e c h a n i s m s ; however, few will produce significant long-term changes in the nature of h o s p i t a l o v e r c r o w d i n g and t~D backup. EDs provide a critically important safety net for our nation's health care system. Unfortunately, our current capacity to meet the needs of our patients is being stretched to the breaking point. Long-term resolution of the problem of hospital and ED overcrowding will require a substantial c o m m i t m e n t of societal resources
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and vision. Successful resolution of this problem will be a monumental task. It is, perhaps, the greatest challenge facing emergency medicine today. The authors acknowledge the contributions of the fellow members of the ACEP Task Force on Hospital and ED Overcrowding: Robert Hockberger, MD, FACEP; E Jackson Allison, MD, FACEP; Charlotte Yeh, MD, FACEP; and Marion Wiseman, ACEP staff. They are also indebted to Maureen Woods Spahr and Carol Conway for their assistance with the preparation of this manuscript.
REFERENCES 1. Lynn SG, Hockberger RS, Kellermann A, et al: A Re port From the American College of Emergency Physicians Task Force on Hospital Overcrowding and Emer gency Department Overload. Dallas, ACEP, September 1989. 2. Patient Overload and Ambulance Diversion Re port and Recommendations of the EMS Task Force. Burlington, Massachusetts Hospital Association, 1988.
3. Fadale J: The Emergency Nurse Perspective. N e w York, ACEP Overcrowding Conference, October 13, 1989. 4. Kellermann A: The National Association of Public Hospitals. New York, ACEP Overcrowding Conference, October 13, 1989.
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5. Gallagher JE, Lynn SG: The etiology of medical gridlock: Causes of emergency department overcrowding in New York City. J Emerg Med 1990;8:785-790. 6. Kotelchnck R: Down and out in the "new Calcutta": New York City's health care crisis. Health/PAC Bulletin 1989;19:4-10. 7. French HW: The poor overwhelm hospitals in New York as they seek care. The Sunday New York Times, December 4, 1988, p L 8. Waters T: In poor health - Some South Bay hospitals struggle to maintain services while caring for the indigent, uninsured. Los Angeles Times, Sunday, May 14, 1989, part II, B:6ft. 9. Lynn SG, Allison EJ, Kellermann A, Yeh, C: Managing the emergency department overloaded with inpatient and ICU boarders, in Comprehensive Guide to Effective Practice Management, ed 2. Dallas, American College of Emergency Physicians, 1991, in press. i0. Storer RH, Hancock WM: A Simulation Study of Parameters Affecting Hospital Unit Occupancy and Implications for Unit Sizing. Ann Arbor, Michigan, University of Michigan, 1976. 11. Sweeney RD: Dear hospital administrator (letter). New York, Office of Health Systems Management, New York Department of Health, December 2, 1988. 12. Sweeney RD: Dear administrator (letter). New York, Office of Health Systems Management, New York Department of Health, January 19, 1990. 13. American College of Emergency Physicians: Emergency department observation units. Ann Emerg Med 1988;17:95-96. 14. A Full House - Hospital Diversion Guiddines: Rec ommendation of the ConnciI of Planning, Committee on EMS. New Jersey Hospital Association, 1990. 15. Dorman HG: Transfer Liaison Resource Book. Mas sachusetts Hospital Association, 1989.
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