Bruchmiller 1

Jacob Bruchmiller

Professor Massie

English 1302

02 April 2019

Proposal to ED Overcrowding: A Possible Solution

Every day people experience life-threatening emergencies and what they perceive as

emergencies. These experiences are often treated by EMT’s, paramedics, nurses and doctors in

their respective environments attempting to grant the victims another day with their loved ones.

A couple holding their lifeless child waiting on an ambulance, a rollover motor vehicle accident

involving two teens, a father suffering a heart attack, these are just examples of true possible life-

threatening emergencies. However, the general population often deems the common cold or

recent onset of the flu, among other non-urgent conditions, to be suitable reasons to visit an

emergency department (ED). Whereas, these are indeed reasons to seek medical advice and

treatment, they provide an accumulating difficulty to the providers attempting to provide life-

saving treatments to those on the verge of breathing their last breath. The challenge ER staff

faces from these non-urgent patients is seen as ED overcrowding. Alas, non-urgent patients are

not the only cause of this problem. To propose a final solution to ED saturation, the extent and

cause of the issue must first be determined. Once the source and degree of the problem have been

identified the answer can be developed and implemented. However, emergency rooms (ER/s)

can start by amending the EMTALA law, encouraging people to seek medical care from

outpatient services, and improve the nation’s psychiatric care.

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Although EDs triage all patients based off an initial acuity, or degree of sickness, an ER

in the U.S. is not allowed to turn patients away, regardless of whether they come in for non-

urgent complaints. A patient’s acuity is determined which is determined by the patient’s

presentation, vital signs, complaint, and their signs and symptoms. The Emergency Medical

Treatment and Active Labor Act (EMTALA) protects all patients from being dismissed. The

initial acuity is reevaluated during a patient’s ER visit depending on changes in their

presentation, vitals, signs and symptoms, or critical results from diagnostic tests. Most facilities

utilize the Emergency Severity Index (ESI) triage tool, which is a tiered triage system that

indicates patient severity from most critical (ESI level 1) to most stable (ESI level 5) (Gilboy).

Unfortunately, there has been an increase in emergency department patient volume over the past

few decades, resulting in ED overcrowding. ED overcrowding combined with low or insufficient

staffing, minimal ED space, and overabundance of patient admissions results in limited space for

critical patients on the verge of dying. This places a strain on ED front line staff attempting to

care for all patients that come through an ER’s doors, regardless of race, creed, sexual

orientation, age, or any other form of discrimination. With the limited space provided by ED

overcrowding and the strain already placed on ED front line staff, it can be difficult to find the

space needed to treat critical life-threatening conditions without making a less critical patient

feeling as if they are being over looked or ignored. This presents an issue evidenced by ER staff

scrambling to move a less critical patient out of the room for a CPR patient being brought by

EMS; as a result, resources that could be utilized to treat the immediate needs of other patients

are rendered unavailable. This kind of situation may leave patients feeling ignored by the staff,

unbeknownst to these patients that the staff is busy performing life saving measures.
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An explanation of EMTALA is required to understand how amending it would assist in

reducing ED overcrowding. Despite what a number of people believe, EMTALA prevents

Medicare-participating hospitals from turning away patients that have not been seen by a

provider. EMTALA requires that these facilities provide a Medical Screening Exam (MSE) to

determine if an Emergency Medical Condition (EMC) is present, and if so, to treat said EMC.

EMTALA also dictates that hospitals with specialty services, such as burn units or trauma

capabilities, can not refuse a transfer in need of said services (“Overview”). Thus, an ER can not

refuse someone from being seen regardless of what their complaint is. Meaning that if a patient

checks into an ED with the complaint of left toe pain, the ED is, by law, required to see this

patient even if the said ED is full and unable to accommodate a room for the patient

immediately. This provides an emergency department with the inability to turn away patients that

should be seen by a primary care provider rather than an ER, notwithstanding their available

space. A vast majority of hospitals, including private hospitals, participate in Medicare, meaning

that they are head to the standards of EMTALA. The issue inlaying with this is that private

hospitals will bill patients to the full extent they are justifiably capable to by Medicare standards.

So, when a patient checks into an ED and receives an MSE that reveals no EMC, the hospital

still continues to treat their non-urgent medical conditions regardless if they could be treated

outpatient by a PCP or specialist. Likewise, ED providers are expected to admit a majority of the

patients that qualify for an overnight stay despite any possibility of being treated outpatient. Here

in lies a portion of the problem seen in ED overcrowding. When a provider is expected to admit

a patient despite the patient qualifying for a discharge to outpatient treatment, it reduces the

amount of space in the hospital for patients that truly need inpatient treatment. In turn, room in

the hospital is eventually reduced to the point that admitted patients are held in the ER, some
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times for hours some times for days; which, subsequentially, reduces the amount of space in an

ED to see patients causing a delay in patients being seen that may have true life-threatening

emergencies. One way to solve this issue would be an amendment to EMTALA that prohibits

hospitals from penalizing providers for discharging patients that should and could seek outpatient

treatment for their medical conditions. By doing this, it would allow ER providers to freely

discharge patients that have no true medical reason to be in the ED after receiving an MSE

proving the absence of an EMC. Likewise, creating a provision of EMTALA that encourages

hospitals to discharge non-urgent patients for them to complete outpatient care would provide a

higher incentive for patients to seek outpatient services. Such a provision could state that “any

patient determined not to be having an EMC and capable of completing outpatient services,

should hereby be discharged to their primary care physician. In addition, these patients should

not receive an admission for subsequent visits of same complaint, unless after MSE an EMC is

discovered requiring admission.” This type of amendment would reduce the stress on the ED

resources, as well as provide the emergency providers to focus on critical patients.

Along the lines of amending EMTALA, hospitals should focus on encouraging the non-

urgent patients to seek outpatient care in the form of primary care physicians or outpatient

specialists. In doing this, it would help alleviate the cost of medical care as well as reducing the

number of patients seen in an ER. Hospitals could accomplish this by providing more education

in what is considered a medical emergency and other resources available to the patients. Urgent

cares, primary care physicians, and specialty physicians are all avenues of care for patients that

do not necessarily need an ER. Most urgent cares have access to imaging services and have

emergency physicians on staff, granted they have limited resources for more critical patients.

However, if patients are educated on the capabilities of these types of facilities, they would be
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more inclined to be seen in one to avoid the cost and wait time of an ED. This provision would

greatly reduce the amount of space taken up by patients that are not experiencing a true medical

emergency.

Another contributing factor to ED overcrowding is the abundance of psychiatric patients

and the amount of time these patients are held in an emergency room. There has been a

significant increase in psychiatric patients over the years. According to a study conducted by the

National Hospital Ambulatory Medical Care Survey, there was an increase of 27.9 to 35.1

psychiatric patients per 1,000 ER visits between the years of 2005 to 2011 (Ayangbayi). There

needs to be a nationwide reform to psychiatric care to make it more affordable to the uninsured

as well as increase the availability or space for inpatient psychiatric facilities, for all patient ages.

The majority of psychiatric patients will spend anywhere from three days to three weeks in an

ER waiting for a transfer to an inpatient facility. This delay is either caused by the lack of

adequate space in these inpatient facilities, or a lack of the right insurance on the patient’s end.

Most true psychiatric patients can not afford the higher end insurances. The U.S. could designate

a higher end insurance similar to Medicare and Medicaid specifically for psychiatric patients to

afford them the ability to be accepted into the inpatient facilities. Likewise, the government

could mandate that hospitals open an inpatient psychiatric care unit within their own facilities. In

conjunction with this mandate, the U.S. could require more inpatient facilities be built to

accommodate areas with higher psychiatric populations. These inpatient hospital psychiatric

units could be designated for those patients that are not expected to need more than a few days of

treatment so as to reduce the number of admissions to the units. Whereas the latter would

provide more availability for those that need more in depth inpatient psychiatric care and reduce
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the times they spend in the ER. Both of these changes would greatly increase the available

resources available to the psychiatric patient population.

For the most part, these solutions would not create many problems for most people and

are extremely feasible. However, like any solution to a problem, there will be those that will

argue against these solutions. For example, hospital corporations will look at the amendments to

EMTALA as a decrease in their revenue due to the reduction of non-urgent patients being seen

and admitted. Whereas this would probably result in less revenue, the benefits of these changes

would reduce wait times for ERs as well as reduce the cost of health care. As for the solution of

government mandates to increase the number of inpatient psychiatric facilities or implementing a

psychiatric Medicare/Medicaid, this would likely result in an increase in taxes for everyone.

However, that would likely be the only con to such a mandate. Psychiatric care would vastly

improve with more inpatient availability and reducing the number of psychiatric patients without

insurance. Over all, the EMTALA changes would truly only affect the hospital corporations

looking for a profit, whereas the psychiatric health care reforms would affect every U.S. citizen

in the form of taxes. Granted an increase in taxes is not an ideal choice for the American people,

providing real health care to this patient population would make ERs and communities safer

from patients that are not receiving adequate mental health treatment.

The issue of ED overcrowding is a potentially dangerous one to the American people,

likewise the American people should be outraged about it. The risks presented by the problem is

evidenced by the lack of resources in the ER for patients that are experiencing a life-threatening

condition. There are feasible solutions to this problem such as restructuring of EMTALA to

guarantee no repercussions for discharging non-urgent patients after finding the absence of an

EMC as well as having hospitals urge patients to seek outpatient care. Along with these
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solutions, a government restructuring for mental health care should be implemented to provide

more resources to this patient population. Providing these provisions would produce a much

more stable environment for the critical patients in need of life-saving treatment. These changes

should be sought after by every American to ensure that emergency medical care is always

available with plenty of resources to provide a patient with every treatment and opportunity to

survive possible. After all, an emergency room is supposed to provide health care in the event of

an emergency.
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Works Cited

Ayangbayi, Toluwalope, et al. “Characteristics of Hospital Emergency Room Visits for Mental

and Substance Use Disorders.” Psychiatric Services, vol. 68, no. 4, 2017, pp. 408–410.,

doi:10.1176/appi.ps.201600125.

Bruffaerts, Ronny. “Emergency Psychiatry in the 21st Century: Critical Issues... : European

Journal of Emergency Medicine.” LWW, 2008, journals.lww.com/euro-

emergencymed/Abstract/2008/10000/Emergency_psychiatry_in_the_21st_century__critica

l.6.aspx.

Cruz, Andres F., et al. GALILEO: Emergency Rooms and Crowd Computing. Sept. 2016,

www.researchgate.net/publication/308007154_GALILEO_Emergency_Rooms_and_Crow

d_Computing.

Gilboy, Nicki, et al. The Emergency Severity Index. Implementation Handbook. 4th ed., U.S.

Dept. of Health and Human Services, Public Health Service, Agency for Healthcare

Research and Quality, 2011.

Honigman, Leah S, et al. “National Study of Non-Urgent Emergency Department Visits and

Associated Resource Utilization.” The Western Journal of Emergency Medicine,

Department of Emergency Medicine, University of California, Irvine School of

Medicine, Nov. 2013, www.ncbi.nlm.nih.gov/pmc/articles/PMC3876304/.

“Overview.” CMS.gov Centers for Medicare & Medicaid Services, 26 Mar. 2012,

www.cms.gov/regulations-and-guidance/legislation/emtala/.
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