Addressing the persistent challenge of emergency department overcrowding
SPMC J Health Care Serv. 2024:10(2):1. ARK: https://n2t.net/ark:/76951/jhcs4c4wn8
1Department of Emergency Medicine, Southern Philippines Medical Center, J.P. Laurel Avenue, Bajada, Davao City
Correspondence Benedict Edward P Valdez, rbenz628@gmail.com
Received 11 July 2024
Accepted 16 September 2024
Cite as Valdez BEP. Addressing the persistent challenge of emergency department overcrowding. SPMC J Health Care Serv. 2024;10(2):1. https://n2t.net/ark:/76951/jhcs4c4wn8
Emergency department (ED) overcrowding has become a significant global health concern, as recognized by the International Federation of Emergency Medicine.1 This issue impacts not only critical care but also the emotional well-being of patients and, in extreme cases, leads to breaches of patient privacy.2 The COVID-19 pandemic has further exacerbated the problem, adding complexity to an already challenging problem.3 ED overcrowding occurs when (1) the number of patients in the ED exceeds the capacity of the hospital’s inpatient services (i.e., wards and ICU),4 5 and (2) the ratio of physicians to waiting patients is insufficient, leading to increased patient wait times.
In the Philippines, overcrowding is a long-standing issue, affecting both government and private hospitals.6 The Southern Philippines Medical Center (SPMC) exemplifies this, with its current ED occupancy rate surging to 193%, far beyond its designed capacity of 80 beds. ED boarding, which refers to holding admitted patients in the ED after they have been admitted or classified under observation status,7 is 150%. In addition, the occupancy rate of adult medical/surgical patients in the ED is 198%, while the volume of the critically ill is 106%. ED overcrowding in SPMC impacts operational efficiency, causing delays in assessment and treatment, an increased risk of cross-infection between patients, and longer radiology and laboratory turnaround times. This problem also leads to reduced patient satisfaction resulting in discharges against medical advice and prompting patients to seek services at other hospitals. However, these patients often return to SPMC shortly thereafter due to the high cost of health services in private hospitals, further contributing to delays in intervention.
This raises the pressing question: why does this preventable issue persist, even in top health care facilities?
Several underlying factors contribute to chronic ED congestion in the Philippines and elsewhere. Insufficient resources—such as limited staff, medical supplies, and equipment—lead to delays in patient care and longer wait times, exacerbating congestion. High patient volumes, particularly during peak times or in areas with limited health care facilities, can quickly overwhelm the ED.8 Furthermore, the lack of access to primary care forces many individuals to seek non-emergency care in EDs, further straining resources. Inefficient patient flow, due to ineffective triage systems, poor coordination between departments, and delays in test results, also plays a significant role in overcrowding.
Limited hospital bed capacity compounds the problem. When there are insufficient beds to admit patients from the ED, it creates backlogs. Complex patient cases requiring extensive evaluation and treatment further tie up resources. External factors, such as natural disasters, disease outbreaks, or mass casualty incidents, can also overwhelm EDs.
Systemic issues, including fragmented health care funding and the regional sharing of specialists, worsen these challenges. Often, health care systems are provider-centered rather than patient-centered, leading to inefficiencies in care delivery.9 The lack of an integrated care and health management system results in fragmented care, hindering effective disease management of diseases and patient outcomes.
Several strategies have been implemented to address overcrowding, particularly in hospitals like SPMC. Efforts to streamline patient referrals within the ED have aimed at facilitating timely and efficient care transfers. Regular resuscitation training and simulation exercises help staff manage emergencies more effectively. Newer emergency medicine specialists benefit from mentorship programs, while continuous quality improvement initiatives focus on optimizing ED processes through staff feedback and performance metrics. Additionally, teamwork and collaboration among health care professionals are promoted, and investments in technology, such as electronic health records and telemedicine platforms, have been made to improve workflow and communication.
The development of unified trauma care teams in EDs has significantly improved admission and turnaround times, even in crowded settings. Collaboration between emergency medicine and surgical teams enables quicker assessments and interventions, improving patient care and reducing delays.
However, these initiatives alone have not fully resolved the overcrowding problem. Standardized referral processes often falter due to inconsistent implementation across departments. Resuscitation and simulation training, while invaluable, focus primarily on emergency response, not the root causes of overcrowding. In response, SPMC launched the Early Ambulatory Surgery for Trauma at the Emergency Room (EASTER), later expanded to include Resuscitation. This initiative alleviates the burden on the main operating room by providing timely trauma interventions, improving patient flow and resource utilization. The EASTER project includes minor operative procedures (e.g., central line placement, wound suturing, nerve block placement, debridement, etc.) that must be performed within 30 minutes to one hour of referral.
While mentorship programs aid professional development, they do not directly address operational challenges in overcrowded EDs. Continuous quality improvement efforts are often hindered by resource shortages and overwhelming patient loads. Although interdisciplinary collaboration is crucial, achieving the necessary cultural shift takes time. Technology, while improving efficiency, cannot resolve the underlying issues of resource scarcity and high patient volumes.
To effectively tackle ED overcrowding, a comprehensive and systemic approach is necessary. Improving access to primary care is crucial to reduce the burden on EDs by preventing non-emergency cases from overwhelming the system. Enhancing resource allocation is also critical to ensure that EDs are adequately staffed and equipped. A shift to a patient-centered model is required to provide coordinated and continuous care across all health care levels.
An e-referral system could improve health care infrastructure by enhancing medical direction and facilitating prehospital care. Integrating prehospital, hospital, and critical care services may not completely eliminate congestion but could potentially reduce mortality rates in overcrowded hospitals. Aligning prehospital and hospital systems, particularly regarding severity levels, has significantly improved resource allocation of hospital resources, ensuring experienced nurses and resuscitation equipment are readily available. Furthermore, equipping medical students with public health education can prepare them for future medical practices.
Expanding hospital capacity, particularly in critical care and isolation units, is essential to better accommodate patient surges. Hospital budget allocation should consider not only bed capacity but also the need to expand services, particularly for specializations that can directly help reduce mortality rates.6 Active bed management is a proactive intervention involving the continuous assessment of hospital services and incoming inpatient flow. It may be carried out by a dedicated bed manager or director who monitors patient admissions, discharges, and patient flow within the hospital.10 11 This process includes regularly making rounds to check bed availability, facilitating expeditious patient transfers, mobilizing available resources (e.g., personnel, hospital spaces, or medical equipment/supplies), and optimizing ED throughput (the time from patient arrival to departure from the ED). Real-time monitoring of bed availability, enabled by bed management software, allows the bed manager to make quicker decisions, especially in acute settings.11
Strengthening public health initiatives to address social determinants of health can reduce the incidence of conditions requiring emergency care. Developing regional health care networks would facilitate better coordination between hospitals, enabling more efficient patient transfers and reducing the strain on any single facility. Outsourcing services is another strategy that hospitals can leverage to reduce patient wait times and improve care delivery.
By adopting these recommendations, we can make significant strides toward resolving ED overcrowding. Focusing on comprehensive solutions and continuous evaluation will help create a more efficient ED system that better serves community needs, improves patient care, and ensures health care facilities can function effectively, even in times of crisis.
Contributors
BEPV conceptualized the article. BEPV wrote the original draft. The author performed the subsequent revisions. The author have agreed to be accountable for all aspects of this report.
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Competing interests
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References
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2 Marchi M. Social and Psychological Effects of Overcrowding in Palestinian Refugee Camps in the West Bank and Gaza - Literature Review and Preliminary Assessment of the Problem. 1999 Aug [cited 2024 Sep 20]. In: Palestinian Refugee ResearchNet [Internet]. Quebec: Palestinian Refugee ResearchNet. C2008. Available from: https://prrn.mcgill.ca/research/papers/marshy.htm?fbclid=IwY2xjawE8931leHRuA2FlbQIxMAABHTQyLaD4aXfzKJvhUQnVKVKYU374IO4bzNeeN4uFxKg_UbIA4KsIUoYMmQ_aem_Ak4adW0uJ9C31VfD9XXnvw.
3 Savioli G, Ceresa IF, Guarnone R, Muzzi A, Novelli V, Ricevuti G, et al. Impact of Coronavirus Disease 2019 Pandemic on Crowding: A Call to Action for Effective Solutions to "Access Block". West J Emerg Med. 2021 Jul 16;22(4):860-870.
4 Australasian College of Emergency Medicine. Position Statement: ED Overcrowding. Melbourne: Australasian College for Emergency Medicine. 2021 Mar [cited 2024 Oct 16]. Available from: https://acem.org.au/getmedia/dd609f9a-9ead-473d-9786-d5518cc58298/S57-Statement-on-ED-Overcrowding-Jul-11-v02.aspx.
5 American College of Emergency Physicians. Crowding. Washington: American College of Emergency Physicians. Updated 2019 Apr [cited 2024 Oct 16]. Available from: https://www.acep.org/patient-care/policy-statements/crowding.
6 Silva MEC, Zarsuelo M-AM, Naria-Maritana MJN, Zordilla ZD, Lam HY, Mendoza MAF, et al. Policy Analysis on Determining Hospital Bed Capacity in Light of Universal Health Care. Acta Med Philipp [Internet]. 2020 Dec 26 [cited 2024 Sep 20];54(6). Available from: https://actamedicaphilippina.upm.edu.ph/index.php/acta/article/view/2596.
7 American College of Emergency Physicians. Definition of Boarded Patient. Washington: American College of Emergency Physicians. Updated 2018 Sep [cited 2024 Oct 16]. Available from: https://www.acep.org/patient-care/policy-statements/definition-of-boarded-patient.
8 Valdez BEP. Crowding Index of Southern Philippines Medical Center [unpublished]. Davao: Southern Philippines Medical Center. 2010.
9 Yu C, Xian Y, Jing T, Bai M, Li X, Li J, et al. More patient-centered care, better healthcare: the association between patient-centered care and healthcare outcomes in inpatients. Front Public Health. 2023 Oct 19;11:1148277.
10 Barchielli C, Vainieri M, Seghieri C, Salutini E, Zoppi P. The Function of Bed Management in Pandemic Times-A Case Study of Reaction Time and Bed Reconversion. Int J Environ Res Public Health. 2023 Jun 19;20(12):6179.
11 Sheasby L. What is bed management? [cited 2024 Oct 16]. In: Access [Internet]. Loughborough: The Access Group. c2024. Available from: https://www.theaccessgroup.com/en-gb/health-social-care/software/bed-management/what-is-bed-management/.
Copyright © 2024 BEP Valdez.
Published
October 16, 2024
Issue
Volume 10 Issue 2 (2024)
Section
Health care focus
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