Overcrowding in the emergency department
Emergency department clinicians are faced with a number of challenges as ED’s become more crowded.
As emergency departments become more and more crowded, emergency department (ED) clinicians are faced with pressures to quickly move patients out of the waiting room and into a place where they can be evaluated and treatment can begin. There are many of problems with this process, and the biggest one is that that emergency rooms are not getting any bigger and more patients are being held in the ED because there are no inpatient beds available.
So far, the solution has been to put patients in beds placed in the hallways, with the thought that they will be moved to a room when one is available. In theory, this practice is a good idea — it's assumed that people would rather have their treatment started in the hallway than sit in the waiting room, creating a shorter ED stay. Some EDs even evaluate their patients while they are still sitting in the waiting room. I am all for shorter ED times, but I question the safety and practicality of this.
I often like to put myself in the position of the patient. I imagine how uncomfortable it is to be told to take your clothes off, put a hospital gown on, sit in an unfamiliar bed, and allow people that you've never met before examine you, usually while asking very personal questions. When I put myself in that position, I realize how uncomfortable a visit to the ED can be. I then picture myself having to go through this while sitting on a bed in the hallway, and I realize just how much I would hate this if I were a patient. I would not be very satisfied with my ED experience. Personally, I would rather wait for a room than to sit uncomfortably in the hallway or discuss my medical care in a non-private setting.
As a clinician, I find myself tailoring the questions I ask and the exam I perform to be more “hallway appropriate.” It is my hope that the patient will soon be moved to a room where I can then ask more in-depth questions and perform the appropriate exam. When the patient finally is moved, I am able to perform tests like digital rectal and pelvic exams; I also re-perform other aspects of the physical exam like evaluating the abdomen. When I can fully expose the abdomen, I sometimes find things that were not apparent on my initial exam, which may change my treatment approach and the tests I want to order. In the end, the patient still has to wait for these tests to be performed. If I want to add any labwork or imaging after my more thorough exam, the total length of time in the ED may not change.
I have also found that asking more in-depth questions once the patient is privately in a room can also change the course of the exam. The patient with abdominal pain may now be more forthcoming with the fact that they have also had unprotected sex and vaginal discharge, facts they did not want to mention while in the hallway because of the other people sitting nearby. This too can change the course of their testing and lengthen their ED stay.
The idea of putting people in the hallways comes from a place of good intentions. However, it is often difficult to move people out of the hallway beds. I often find that by the time a room becomes available, there is a more critical patient who needs that room. Clinicians are often faced with the difficulty of having to juggle patients in and out of any available space, quickly performing thorough exams and then putting patients back into the hallway to open up the room again.
Because we cannot easily create more inpatient beds with appropriate staffing or expand emergency departments, clinicians have to make the best out of the situation at hand. I think one of the most practical things we can do is to really make an effort to move stable patients, or patients with plans for impending discharge, into the hallway to open rooms for new patients. This way, we can ensure we are getting the best history and physical exam as possible the first time, and eliminating the need to obtain any personal information in the waiting room or the hallway. While it's a small step, I think that it could make a big difference towards patient care and their satisfaction in the ED.
Jillian Knowels, MMS, PA-C, works as an emergency medicine physician assistant in the Philadelphia area.