Emergency Department Crowding, Part 2—Barriers to Reform and Strategies to Overcome Them

Use of Out-of-Hours Services: The Patient’s Point of View on Co-Payment a Mixed Methods Approach

“…The rationale for cost sharing is often based on the moral hazard argument, which states that individuals may overuse care if they do not share in its costs (22). On the other side of the spectrum, the risk of overuse exists for the wealthy (8,23,24).…”

“…Since the 1990s, policy makers and physicians have tried to redirect patient flows of minor medical problems to primary care (6)(7)(8). Making primary health care more accessible during out-of-hours by implementing general practitioner cooperatives (GPC) is one of the measures that may show effective over time (9).…”

Implementing Triage Standing Orders in the Emergency Department Leads to Reduced Physician-to-Disposition Times

“…As the ED system is overburdened by crowding, the quality and safety of emergency care decline. Direct consequences of crowding include increased wait times [4,5,10,11], increased rates of patients leaving without being seen [7,[9][10][11], prolonged LOS [3,7,8], higher patient dissatisfaction [3, 5, 7-9, 11, 12], poorer clinical outcomes [3,5,7,9], delay in time-sensitive interventions [4,7,10,11,[13][14][15], increased adverse events [7,10], increased ambulance diversion [3-5, 7-11], decreased regional disaster response capacity [3], increased morbidity and mortality [3,4,7,9,10,[16][17][18], increased number of patients returning to the ED [7], and ED staff dissatisfaction and burnout [5,8,10]. Crowding is attributed to 31% of sentinel events in the ED [4].…”

“…Despite the increase in patient volume and complexity, hospital and ED resources have not increased proportionately. Instead, during this same period, the number of EDs decreased by 381, the number of hospitals decreased by 535, and the number of inpatient hospital beds decreased by 134,000 [1][2][3][4].…”

“…Throughout the United States, emergency departments (EDs) are called upon to care for more and more patients; from 1995 to 2005, annual ED visits increased by 20% and ED utilization increased by 7%, from 36.9 to 39.6 ED visits per 100 persons [1][2][3][4][5]. In addition, the multifaceted scope of emergency care has broadened to encompass care of indigent patients, stabilization of the acutely ill, proficiency in procedures, medical observation, and primary healthcare [4]. Despite the increase in patient volume and complexity, hospital and ED resources have not increased proportionately.…”