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Crowding is a serious problem in emergency departments (EDs) in the United States and abroad.1-5 It is considered by most emergency physicians to be the greatest safety risk for patients, greater than timeout for procedures, handwashing, antibiotic timing for pneumonia, and, in larger hospitals, greater than availability of specialty consults.6

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Multiple studies and the US Government Accounting Office agree that the primary cause of crowding in the United States is the practice of boarding, the holding of patients already admitted to the hospital in the ED.7-12 This practice has been associated with an increase in errors,13,14 increased costs,15 delays in care,16-21 an increase in morbidity,22-24 and an increase in mortality.25-27 The Joint Commission has determined that 50% of sentinel events causing injury or death occur in the ED, and at least one-third of those are related to crowding.28

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Hospitals resort to boarding patients in the ED when there is a shortage of beds or nurses on the inpatient floor to handle the admission. Historically, with the failure to anticipate and plan for inadequate inpatient capacity in hospitals, the ED became the repository of these excess patients. Crowding increased as the number of admissions entered through the ED increased. Also, as an unplanned adaptation to boarding, the ED became the default provider for these patients, in spite of an influx of new and sick patients. Unfortunately the practice has become pervasive and boarding times have become prolonged with multiple ED handoffs occurring (ED doctor to ED doctor and ED nurse to ED nurse).

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Some hospitals have realized that inpatients residing the ED may be more expensive to manage with lower reimbursement.29-32 Admissions from the ED are largely medical; surgical patients have a higher contribution margin (greater profit). As a result, hospitals may prioritize elective surgical admissions over “routine” ED admissions. Some teaching hospitals attract national and international referrals, yet they are situated in low-income neighborhoods. Such institutions may prioritize their beds to the better insured referrals, thereby limiting the number of ED patients who can be admitted. At the extreme of this practice are hospitals that geographically limit beds to specific specialties, limiting resources for perceived less profitable cases, leading to extensive ED boarding of these inpatient cases.

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Consequences of ED Crowding

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Unfortunately, a consequence of boarding is a greater length of stay (LOS) and greater cost to the hospital.33,34 Several studies have shown that patients boarded in the ED have a longer hospital stay.35,36 Other studies have shown that the hospital charges are substantially greater for patients who are boarded in the ED.37 Recently Massachusetts developed a statewide plan to reduce boarding and end ambulance diversion, described later. Preliminary data from those hospitals that have reduced boarding show that they have increased their profit margin.

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The decreased ED availability related to beds ...

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