Finding the Root Causes of Emergency Room Overcrowding

Identifying the root cause of a problem is a fundamental lean principle. That is the reason we ask “why” five times. Knowing the root cause is critical to achieving true improvement.

A new survey by a group of researchers, published in the Annals of Emergency Medicine, does an excellent job of looking at the root causes of emergency room overcrowding.

The ER is the focus of many current improvement initiatives in healthcare because of frequent overcrowding and long delays in patients being seen by doctors. Many initiatives focus on streamlining processes and improving patient flow, or patient throughput, so that there is less waiting time, and more patients can be seen.

That is all well and good. But the new research takes a step back to ask why ERs are overcrowded.

It is already well-known that demand for ER services has increased significantly in recent years. Conventional wisdom tells us that the cause is growing numbers of uninsured patients using the ER as their primary source of healthcare.

However, the new research demonstrates that conventional wisdom is wrong. The researchers used data from the national Community Tracking Study Household surveys for four different time periods between 1996 and 2004. They connected ER (or ED, for emergency department) visits to insurance status, family income, usual source of care and other factors.

Their findings: The proportion of visits by uninsured persons has not increased. However, there has been an increase in the proportion of visits by people whose usual source of care is a doctor’s office. The authors comment:

Our results provide strong evidence that visits by uninsured persons during this period were not a major cause of the overall increase…

These findings suggest that the rise in ED use is disproportionately due to non-poor individuals who have a usual source of health care. These findings have significant implications for current policy discussions because they suggest that the provision of health insurance will not, in and of itself, address issues of ED crowding or the more general issues of access to, and appropriateness of, health care services…

There are many factors contributing to the rise in ED visits, including population increases, the aging of our population, the increased numbers of time-sensitive interventions requiring state-of-the-art hospital care, larger numbers of patients with complex medical problems requiring evaluation in a setting in which sophisticated testing and consultation are available, and complications from medical and surgical treatments.

Another reason for increased ED use may be difficulty obtaining timely appointments from one’s usual source of care, or physician referrals to EDs because of their diagnostic and treatment capabilities.

Thus, the uninsured are not primarily responsible for the increase in ED utilization. Instead, the increase in ED use may be attributable to lack of ready access to primary care and other structural problems in the health care system.

The next step is to identify and come up with ways to address those structural problems. Now the real work begins.