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Hospital Services; Hospitals


Emergency department crowding and delays have become major issues for America's safety net hospitals and health systems. Many facilities are experiencing increasing wait times, a need to "board" admitted patients in emergency department (ED) hallways, and rising numbers of hours spent on "diversion" or "bypass." These trends result from increased patient demand at a time when the number of emergency departments has declined and hospital inpatient capacity has lagged. Other factors also may contribute to the crisis. Patients without access to medical specialists may view the ED as the quickest route to specialized services. Overburdened physicians may be more likely to refer patients to an ED for care, especially if they view the ED as a comprehensive diagnostic center. Meanwhile, shortages of nurses and on-call specialists may slow the care of patients once they get to the ED. Given these complex factors, solutions we once thought would relieve ED demand, like expanded primary care capacity, may actually do little to alleviate this crisis.

For patients as well as caregivers, these are more than issues of convenience. Many of the patients who, due to their frustration at the long wait, leave a hospital ED without being seen by a physician do indeed need immediate medical care. Overworked health professionals are more prone to error, and a crowded ED is more likely to experience high turnover and vacancy rates. Long delays and overextended staffing are recipes for low quality, medical error, and poor morale.

Faced with the unique mandate of the Emergency Medical Treatment and Labor Act of 1986 (EMTALA), as well as with historic missions to care for all, safety net hospitals may be especially strained by these conditions. These hospitals often run large emergency departments with trauma and other specialized services and treat many medically and socially complex patients in an environment of declining or no payment. Yet they are expected to care for all comers, and to do it well while being accountable to the public.

The National Association of Public Hospitals and Health Systems (NAPH) commissioned this report, Perfecting Patient Flow: America's Safety Net Hospitals and Emergency Department Crowding, to describe practical approaches to reducing ED crowding as implemented in three member hospitals. Each of these hospitals participated in the year-long Robert Wood Johnson Foundation-funded safety net collaborative, Urgent Matters. These three hospitals, The Regional Medical Center at Memphis, Boston Medical Center, and Grady Health System in Atlanta, were chosen through a highly selective process to participate in the project, which was headquartered at The George Washington University Medical Center School of Public Health and Health Services.


Funder: Robert Wood Johnson Foundation.

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