Emergency department overcrowding: peering through the holes in the safety net.

In this issue of CJEM, Ospina and colleagues provide an important addition to the emergency medicine literature on the indicators of overcrowding in Canadian emergency departments (EDs). Their efforts to define overcrowding and derive scientific tools to measure and correct it are admirable. Nonetheless, I was struck by their statement that “A more consistent approach that focuses on standardized indicators of events occurring in the ED would help distinguish between the causes, characteristics and outcomes of overcrowding.” We can likely agree on the harm of ED overcrowding — errors in care, delays in treatment, patient dissatisfaction and staff burnout and turnover. ED overcrowding is a challenge that urgently needs a solution. Yet like many labyrinthine problems, taking the wrong path is unlikely to determine a way out. In my view, we must be particularly careful not to confuse improving overcrowding measures with improving emergency care, as these do not necessarily go hand in hand. Once the indicators most able to identify overcrowding are established, the next step may be to identify metrics that best reflect those indicators. What if improving overcrowding metrics has minimal or no effect on health care outcomes? One could envision scenarios in which, for example, increasing the number of staffed acute care beds or improving emergency physician satisfaction had no effect on patient health. Or similarly, as appears to have happened in the United Kingdom, decreasing the ED length of stay by rapidly admitting more complex patients to inpatient beds or “medical assessment” wards may have no effect or even detrimental ones on cost and expeditious patient care; and while some busy EDs have improved their time to physician assessment by staffing a physician at the triage desk, it remains uncertain whether this consistently improves patient flow, treatment or even satisfaction. Moreover, it is unclear whether this is a cost-effective use of physician resources. The United States automobile industry is still learning the bitter lessons of process improvement, despite sophisticated management tools such as Six Sigma, Lean and reengineering. Blind adherence to process improvement, without careful evaluation of the resulting customer impact, can produce a faster assembly line cranking out cars nobody wants to buy. Similarly, teaching students to improve standardized test scores does not necessarily improve the life skills that education aspires to teach. Health care, like car manufacturing or education, demands a clear vision of the desired endpoints before reflexively tinkering with the processes.