Hospitals across the country are struggling mightily to solve the problem of overcrowded emergency departments. They're testing everything from redesigned triage processes to so-called "smoothing" of elective surgery schedules to make more inpatient beds available for people admitted from the ED.

The pressure on EDs already is critical, even before 32 million previously uninsured Americans get health care coverage under the Affordable Care Act. While providers say they look forward to the new paying patients, they worry that the shortage of primary care providers will force many to seek care in emergency departments.

In Massachusetts, which greatly expanded health care coverage through a program similar to the ACA, ED use rose 7 percent and ED costs surged 17 percent, according to a 2009 study by the Robert Woods Johnson Foundation.

Nationally, ED visits grew to nearly 124 million in 2008, up from 117 million the year before, the Centers for Disease Control and Prevention reports. An Institute of Medicine study found that 500,000 ambulances were diverted in 2006.

Sandra Schneider, M.D., president of the American College of Emergency Physicians, says some politicians inaccurately blame ED overcrowding on uninsured patients who seek care for nonemergent ailments. "While there clearly are some unnecessary visits to the ED, the CDC study finds only 8 percent of ED patients could wait between two and 24 hours for care," she says. "Ninety-two percent of those ED patients needed to be there."

Patients presenting on Friday nights might not receive care anywhere else for 48 hours. "If you badly sprain your ankle on a Friday night, is it in your best interest to wait until Monday and call off work to see your doctor, or is it more cost-effective to get it taken care of on Friday and go to work on Monday?" she asks.

As more primary care physicians refuse Medicare and Medicaid, those patients have nowhere else to go but the ED, Schneider says. "If we get a patient in with massive trauma, we can spend an hour saving that person's life, and in New York Medicaid pays a flat rate of $26, regardless of how much we've done. To collect that costs $10, netting us a reimbursement of $16. You don't find many professionals willing to work for $16. That's why the charges for those who can pay go up."

Jesse M. Pines, M.D, an ED physician and director of the Center for Health Care Quality at the George Washington University Medical Center in Washington, D.C., warns that "there is a fair amount of data showing how crowding itself, the boarding issue and long waiting periods for ED beds are leading to higher rates of complications and higher mortality."

The National Quality Forum approved several measures for ED crowding, such as length of stay, how long it takes to see a physician and leaving the ED without being seen. They will be included among the Centers for Medicare and Medicaid Services' Hospital Compare measures in the next few years. "What's measured gets improved," Pines says.

Hospitals approach ED crowding in multiple ways, says Pines, the principal investigator for the Robert Wood Johnson-funded emergency medicine e-newsletter, Urgent Matters ( For instance, reorganizing the way triage is performed can expedite care by getting decision-makers to patients as early in the process as possible.

Another strategy is to start certain services even before a patient is seen by a physician. "People are getting tests and treatments sooner and moving through the system faster, so fewer patients are leaving without being seen," he says.

That model sorts patients into three categories: critically ill, fast-tracked (minor injuries or sicknesses requiring few resources) and those who are not critically ill, but require more services, such as labs, CT scans, medication or expert consulting.

The Great Bed Hunt

One big reason for ED overcrowding is the competiton for inpatient beds between patients admitted through the ED and those admitted after surgeries, deliveries or the cath lab. The ebb and flow of emergency cases is unpredictable and can't be controlled. However, Ellis Knight, M.D., senior vice president of ambulatory services at Palmetto Health in Columbia, S.C., says hospitals can control the pace of scheduled admissions.

"What drives scheduling is physician preference," he says. "Nobody wants to operate on Mondays, Fridays or weekends. And when we get big peaks from the ED [at those times], it clogs up the system, leading to overcrowding, boarding and diversions."

Eugene Litvak, a professor at the Harvard School of Public Health and the president and CEO of the Institute of Healthcare Optimization in Boston, says most hospitals continue to set staffing levels to accommodate the average between the peaks and valleys of daily occupancy. "When we experience peaks above that staffing level, the whole system goes crazy," he says. "The ED gets overcrowded and we see ambulance diversions. Patient health is at risk and nurses get stressed out. Hospital EDs become parking lots that take time to clear."

Like Knight, Litvak blames poor scheduling of elective admissions—what he describes as artificial variability. Litvak says huge peaks and valleys in hospital occupancy—60 to 80 percent variation between two consecutive days—can dramatically impact staffing, stress staff, erode morale, cost hospitals unnecessary overtime and put patients at risk. He says by better managing elective admissions, those peaks can vary by as little as 10 to 15 percent, a more manageable variation.

Managing throughput offers benefits far beyond the ED.

Cincinnati Children's Hospital Medical Center had budgeted for 100 new beds, Litvak says, but after coordinating surgery schedules it didn't need to add any. "At a capital cost of around $1 million per bed, they saved more than $100 million and their census moved up from 76 to 91 percent. Increasing bed capacity by 15 percent was worth another $137 million a year to them."

Canadian hospitals boast a 90 percent occupancy rate, compared with the U.S. average of 67 percent. "One-third of our beds are empty and we are still overcrowded?" Litvak says. "Why? Because of artificial variability—-those peaks. We can go up to 80 percent occupancy without adding any new beds if we smooth those artificial peaks."

Peter Viccellio, M.D., vice chairman and clinical director of the ED at Stony Brook (N.Y.) University Medical Center, describes hospital overcrowding as "trying to fit a seven-day-a-week problem into a five-day-a-week solution."

Viccellio says 30 to 40 years ago, when most hospital admissions were elective and scheduled, hospital managers could run a 9 to 5, Monday through Friday operation. "Now patients come in seven days a week. My ER sees the same number of people on weekends as weekdays."

Stony Brook's strategy is called "full-capacity protocol," he says. When ED patients are admitted to units lacking available beds, they aren't boarded in the ED, but instead are moved to the next most appropriate beds. If no floor beds are available, patients are transported to acute care unit hallways. Each hospital unit accepts one or two patients, spreading the load rather than having 30 or 40 boarders cramming the ED hallways. Viccellio says the nurse-patient staffing ratios don't grow significantly and ED patients continue to flow through and get discharged.

"The most important and sustained impact is that the hospital knows that when we have boarders like this, it's not an ED problem, it's an institutional problem," he says.

Winning Over Doctors

Knight acknowledges that "smoothing" surgical schedules is a challenge. "Is it easy to convince doctors this is the way to go?" he asks. "No, but hospitals can no longer say 'forget about it' to avoid ticking off doctors. They have to figure out ways to align themselves more with their physicians or the system will implode."

Palmetto Health targeted its employed surgeons and surgeons affiliated with its accountable care organization. They receive extra compensation for maintaining a consistent schedule for procedures and bonuses when improved throughput saves on costs.

"Before we tried this at Palmetto Health, we had surgeons frequently tied up with long wait times to do urgent or emergent surgical cases," Knight says. "We separated elective schedules from emergency surgery schedules and our wait times went down significantly, and surgeon satisfaction went up dramatically. ED throughput increased and created more opportunity for revenue and capacity, all things that surgeons covet."

Caroline Steinberg, the American Hospital Association's vice president for trends analysis, says ED capacity troubles are emblematic of deeper problems in the health care system. The AHA has worked on policy issues like health care workforce shortages and reimbursement increases that indirectly relieve pressure on hospital EDs.

She says the reform law addresses rising numbers of uninsured for whom the ED traditionally has been the only option, but only to a point. "Greater coverage of the uninsured and the Medicaid expansions should help, though Medicaid patients tend to be higher users of EDs and low Medicaid payments for providers often leave those patients with few options for care."

Other Strategies

Hospital leaders also are exploring process changes, technology tools and social services solutions to confront their ED problems.

Rhonda Sonson, director of critical care and emergency services for the Methodist Hospitals in Northwest Indiana, says the issue can be as basic as transportation. "Some of our patients can't get to their primary care doctors because there is no public transit system where they live," she explains. "So we try to give them cab fare. Some can't afford their medications, so we steer them to pharmacies offering $4 drugs. If you don't fix those little things, they'll come back to the ER."

More than 85 percent of patients discharged from Methodist Hospitals' EDs receive callbacks from nurses who inquire about pain, unusual symptoms or anything new.

Michael McGee, M.D., medical director for Methodist's two EDs, says lack of on-call specialists is a chronic problem. "There is a shortage of orthopedic and neurosurgeons," he says. "Those who do take call are up all night and that affects their practices the next day. So I don't blame them for rejecting on call or asking for compensation."

He says specialist shortages are a big reasons hospitals must transfer emergency patients to another facility. "We pay specialists to take call," he says. "For us, it's worth it."

Mark Taylor is a freelance writer living in Munster, Ind.