By Anne Harding

NEW YORK (Reuters Health) - Crowding in emergency departments leads to longer waits and delays in care for all but the very sickest patients, according to a study of four different ERs.

Waits of five to six hours have become the norm, Dr. Melissa L. McCarthy of Johns Hopkins University School of Medicine in Baltimore, the study's lead author, told Reuters Health. And the arrival of flu season -- with not just one, but two, strains to worry about -- has only made things worse, she added.

While it would seem intuitive that patients would have to wait longer in crowded ERs, until recently it has been difficult to actually measure crowding in an accurate way, given that crowding can fluctuate dramatically during a patient's stay.

McCarthy and her team addressed this by looking at crowding every half-hour from the time the patient arrived at the emergency department to the time they either were discharged or were admitted to the hospital.

Over 12 months, they studied four busy emergency departments at academic medical centers, all with Level 1 trauma centers, including 226,534 patient visits in all.

They report in the Annals of Emergency Medicine that patients spent a longer time in the waiting room under crowded conditions. Boarding time -- meaning the amount of time a patient spent in an emergency department bed while waiting for an inpatient bed -- also increased with crowding. While crowding also affected how long it took for patients to be treated, the effect wasn't as large.

"Although it is reassuring that the treatment time is least affected, both waiting and boarding are high risk," the authors of a commentary on the study point out. "Both represent times at which disease can rapidly evolve and go unnoticed, exposing patients to preventable adverse events."

Wait time for the very sickest patients, those would die without being treated promptly (for example, someone whose heart had stopped or who wasn't breathing) was not affected by crowding. But patients who were in the next tier down, for example someone with chest pain or signs of stroke, did have to wait longer in crowded conditions.

Contrary to popular opinion, McCarthy noted, ER waiting rooms aren't getting more crowded because more uninsured people are relying on them for care. "The real problem that's causing the crowding is the boarding time," she said.

And the fact that many hospital beds are reserved for higher-paying patients, for example someone undergoing elective heart surgery, makes matters worse. "Financial incentives aren't aligned properly for good patient care," she said.

"It's depressing right now to be working in an emergency department," McCarthy said. "It seems like no matter what we're trying, it's not working."

"A lot of this crowding is just system problems within the hospital," she added. And the most promising approaches to fixing these problems involve making changes to the system, for example, using engineering-type approaches to redesigning patient care flow.

"One of the benchmarks of any industry is service completion time," McCarthy said. "As a health care industry, we just have to figure out how to get these completion times shorter."

In their commentary -- Dr. Jesse M. Pines of the University of Pennsylvania in Philadelphia and Dr. Donald M. Yealy of the University of Pittsburgh School of Medicine --say ER patients have become "the unfortunate 'canaries in the coal mine' in a dysfunctional health care system."

SOURCE: Annals of Emergency Medicine, October 2009.

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