By David Graves

To break up a traffic jam on a narrow street, vehicles should file down one at a time, evenly paced. If you want to find a temporary solution to emergency department diversions, hospitals must find a way to space admissions so that patient traffic jams are not created.

That's the message from Eugene Litvak, Ph.D., a professor of management at Boston University. For the past year, Dr. Litvak has been studying the issue of emergency department diversions through a grant from the Massachusetts Department of Public Health (DPH).

"The purpose of the study was, in part, to test the hypothesis that the voluntary scheduling of surgeries had an impact on diversions from emergency rooms," said Paul Dreyer, DPH deputy director of Health Quality Management. "The findings that we have seen are suggesting that this is the case."

Initial news reports of Dr. Litvak's study implied that scheduled surgeries were the only cause of diversions, but Dr. Litvak says the problem is much greater than that.

"Operating room schedules can be made more efficient, but that's just one point of admission to the hospital," says Dr. Litvak, who adds that increasing the capacity of emergency departments will not end the overcrowding.

A Question of Resources
His study shows no correlation between emergency department patient arrivals and diversions. Rather, he says the problem occurs when admissions from other hospital departments take up needed beds. The study is designed to examine patient flow throughout the hospital and determine if better scheduling practices will alleviate over utilization of hospital resources.

"Doctors, hospitals and insurers think that it's an issue of the number of beds needed," says Dr. Litvak. "They think they all have the number. This study will show us how many beds are justified."

The overtaxing of hospital resources to the point of shutdown is not a recent phenomenon. The topic has been covered in the pages of Vital Signs before (December 1999/January 2000 and January 2002). This study, however, marks the first time that analysts have looked at specific issues of resource management within hospitals as a means to reduce the number of diversions.

Dr. Litvak gathered his data from two Boston-area hospitals, Massachusetts General Hospital and Leahy Clinic. More than 6,000 admissions, 8,000 emergency department visits and 300,000 data points covering individual patient movements within the hospitals were analyzed.

Most of the early studies on emergency department diversions concentrated solely on the inflow of patients to the emergency department. A 1992 General Accounting Office study concluded that the problem was confined to large urban hospitals and caused primarily by patients seeking treatment in emergency rooms for non-urgent problems. The issue of crowded emergency departments eased later in the 1990s as individual hospitals enacted measures to cope with the problem. However, an article published in the October 2002 issue of The Annals of Emergency Medicine (2002;40:388–393) cites a recent nationwide survey showing that 91% of the hospital emergency department managers who responded said crowding was a problem in their departments.

A Chronic Condition
Only recently have researchers such as Dr. Litvak and his team looked beyond the inflow of patients to emergency departments as the reason for their crowded conditions and subsequent diversions. The Annals of Emergency Medicine article list the following among "the U.S. health care systems' chronic problems": large numbers of uninsured people, workforce shortages, rising health care costs. When these and other issues are coupled with the "recent shortage of staffed inpatient hospital beds," it suggests that the diversion issue is multifaceted.

At least one Massachusetts surgeon agrees that staffing shortages is a main reason for crowded emergency departments.

"The shortage of beds is just one issue," says David Jackson, M.D., a general surgeon at Cooley-Dickinson Hospital in Northampton and a member of the Massachusetts Medical Society's Board of Trustees. "There are times when there are enough beds, but not enough nurses to staff them."

In fact, Dr. Litvak agrees that just supplying more beds is not the answer, and there may not be a permanent solution to the problem of diversions. "The question we have to ask is what is the level of diversion that hospitals are willing to accept," he says.

Managing the Flow
Another co-investigator in the study agrees that the scheduling problems are not confined solely to surgery. "Surgeons didn't create this problem," said Michael McManus, M.D., associate director of ICU at Children's Hospital in Boston.

"Surgeons have adjusted their lives around a scheduling practice that doesn't work well. This study is about finding a way to schedule activities within the hospital so that the census can be spread out to avoid overloading."

Dr. McManus notes that the solution to overcrowding is to be found in how patients arrive at the hospital. He believes there are a number of procedures conducted in hospitals that lead to admissions that could be better coordinated. He mentions cardiac catheterizations as one example.

A recent Boston Globe story on overcrowded hospitals ("Surge of Patients Taxes Hospital Resources," Sept. 22, 2002) noted that the New England Medical Center (NEMC) is doing cardiac catheterizations when patients are admitted, rather than waiting until the following day to expedite the movement of patients through the facility.

At Lawrence General Hospital, the administration has taken steps to improve scheduling in several units. Some units that previously operated around the clock have cut back hours to maximize available staffing, Cardiac stress tests have been rescheduled away from peak admissions times. And surgeons constantly monitor operating room schedules to avoid crowding that could lead to diversions.

"The results of our efforts to date are very encouraging," says Richard Iseke, vice president of clinical affairs at Lawrence General. "Our data is preliminary, but we've seen fewer diversions from August of last year to this August."

However, Dr. Iseke believes that doing a better job of scheduling is a short-term solution to the problem of crowding. "If you don't increase inpatient capacity," he warns, "you don't solve the problem."

Bed Capacity Counts
The same Boston Globe story noted that NEMC recently opened a 10-bed heart failure unit and that Bay State Medical Center in Springfield will be adding nearly 50 new beds over a three-year period. This expansion is a reversal of trends in the 1990s during which the Massachusetts Division of Health Care Finance and Policy estimates that one-fourth of the state's acute care hospitals closed and 28% of available hospital beds were eliminated.

"There was excess capacity in the system," says Alan Woodward, M.D., who runs Emergency Services at Emerson Hospital in Concord and serves as vice president of MMS. "But we never identified the end point where we needed to stop cutting. We're now seeing the crunch that could have easily been anticipated."

Stopgaps or Solutions?
Dr. Woodward sees the need for a universal effort to solve the problem of hospital crowding and emergency department diversions.

"We all have to work on this," he notes. "We've allowed the resources to dwindle well below what's needed to meet demand. It's going to be everybody's task to figure this out over the next couple of years."

Dr. Iseke believes that the MMS can and should take a leading role in determining a solution to overcrowded hospitals. "We must educate the public and our legislators on the fact that a lack of resources in our hospitals limits access to medical care."

The ultimate goal of the Litvak study is to bring more efficiency and better utilization of all hospital resources to bear for the well-being of the patient. "Better management decisions will improve the quality of clinical care," insists Dr. Litvak.

Dr. McManus expresses it best from a time-management perspective. "The overall principle here is that when flow patterns are not erratic, you are more efficient," he says.

No one, however, appears optimistic that overcrowding of our hospitals will end any time soon.

"The demands brought on by an aging population are going to expand exponentially over the next 10 to 15 years," predicts Dr. Woodward. "We have already surpassed the end point of the [health care] system's ability to handle demand. We now have to somehow maximize the resources that exist in the system."