March 2011 Volume 7 Number 7

Hospital Emergency Department Crowding and End of Life Care

By Matthew R. Herington, JD, MPH, Montana Department of Public Health and Human Services, Helena, MT and Aaron C. Herington, MD, East Carolina University, Greenville, NC

AuthorAuthorWithout question, hospital emergency departments (EDs) across the United States are crowded. Referred to in a recent report by the Institute of Medicine as a “national epidemic,”1 ED crowding is a major problem in the US that is adversely affecting quality of care and raising serious ethical concerns. At the same time, with the aging of the US population, an increasing percentage of the population will be living with chronic diseases in the coming years. Treating these patients in the ED can be complex and require a large amount of resources. A certain percentage of these patients will die as a result of their chronic disease, and will present to the ED for medical problems stemming from that disease that arise during the last few months of their lives. Thus, a key issue in the coming years will be how to address ED crowding while, at the same time, providing quality end of life care for an aging population with a high prevalence of chronic disease. In addressing this issue, it is critical to take a closer look at the scope of the ED crowding problem in the United States, as well as at its causes.

The Scope and Etiology of Emergency Department Crowding
As defined by the American College of Emergency Physicians, “[c]rowding o ccurs when the identified need for emergency services exceeds available resources for patient care in the emergency department (ED), hospital, or both.”2 It is difficult to exactly quantify how much of a problem ED crowding is in the United States, although clearly a large number of hospitals perceive their EDs to be crowded. A large, random sample survey of several hundred ED directors across the country found that greater than 90 percent of these directors believed that “overcrowding” was a problem at their hospital.3 These results were found to be similar across hospital types (academic, county, and private) and geography. Similarly, a report issued from the Centers for Disease Control and Prevention in 2006 found that nearly two-thirds of EDs in metropolitan areas were experiencing crowding.4

The reasons why EDs across the country are crowded have been debated by health policymakers and healthcare workers, and opinions on the subject have varied over the years. Nevertheless, a couple of potential factors have been identified.

First of all, the enactment of the Emergency Medical Treatment and Active Labor Act (EMTALA) in 1986 mandated that patients presenting to the ED with a complaint about their health must be assessed. Specifically, EMTALA states that “ if any individual…comes to the emergency department and a request is made on the individual’s behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate medical screening examination within the capability of the hospital’s emergency department, to determine whether or not an emergency medical condition…exists.”5 If the hospital determines that an emergency medical condition does exist, the hospital must either treat the patient6 or transfer the patient to another medical facility (within certain limitations).7 The Emergency Medical Treatment and Active Labor Act was enacted in response to allegations of “patient dumping,” which involved private hospital EDs either not providing needed care to patients or transferring medically unstable patients to a public hospital based on an inability of the patient to pay. Obviously, when time is of the essence, such actions can result in adverse health outcomes for the patient, including death.

However noble the intentions behind the law may have been, there has been a serious problem- EMTALA is an unfunded mandate. If a hospital chooses to participate in Medicare, and offers emergency services, it is required to abide by EMTALA; however, no additional funding is provided to hospitals to help them comply with the law. As a result, the hospitals must absorb the costs for those who are unable to pay. It is argued by some that EMTALA has contributed to both decreased access to and quality of emergency care in the United States. Supporters of this view point to the fact that, over the last two decades, the number of EDs in the United States has seen a steady decline. At the same time, the total number of ED visits has increased.8 Thus, it could be argued that the enactment of EMTALA has resulted in an increase in ED crowding. Proponents of this view claim that non-urgent, unnecessary visits to the ED- spurred on by EMTALA- are the main cause of the ED crowding crisis.9

A different view is that, in fact, a practice known as “boarding” is largely responsible for ED overcrowding. Boarding is the practice of holding patients who need to be admitted to the hospital in the ED until an inpatient bed becomes available.10 Beds may not be available because the hospital is already at full capacity, or because beds are not available in the specific area of the hospital where the patient needs to be placed. Consequently, these patients have to be cared for in the ED for an indeterminate length of time- in some cases, literally for days. Of course, while these patients are being boarded, new patients are arriving to the ED. In order to continue to see new patients while the previous patients are being boarded, it can become necessary for the boarded patients to be placed in the hallways of the ED, on stretchers or in chairs. Since these boarded patients often have serious medical concerns, they often require intense monitoring and resources. Some of these boarded patients have terminal illnesses, and are in the last stages of their lives. Boarding is increasingly being recognized as one of the main causes of ED crowding. Recognized as such in a General Accounting Office report in 2003,11 this view was also endorsed by an American College of Emergency Physicians task force report in 2008.12 Although the early studies examining the causes of ED crowding tended to focus on so-called “input” factors (e.g. patients using the ED for non-emergent care), more recent research demonstrates that “output” factors (e.g. a lack of inpatient hospital beds and subsequent boarding) are in fact the main drivers of ED crowding.13

The Relationship between Emergency Department Crowding and End of Life Care
The provision of end of life care in the ED can contribute to an increase in crowding, in part due to increasing boarding. Additionally, ED crowding can lead to a decrease in the quality of end of life care that is provided in the ED. There are several reasons for these relationships.

Emergency department staff are trained to look for emergencies first and foremost, and to treat immediately reversible causes of a patient’s symptoms. With chronic diseases, the underlying disease goes unchanged and many of the needs of the patient go unfulfilled, resulting in frustration and return visits for similar complaints. All too often, patients with an end stage disease will come to the ED and receive acutely life sustaining treatments which they may not have wanted. In an emergency situation, the ED staff often needs to act immediately, and may be unable to fully discuss treatment options with the patient and family. This can result in patients receiving intensive treatments in the ED, followed by boarding, and subsequent hospitalization- often with no improvement in quality of life for the patient. Those patients who are hospitalized can remain hospitalized for some time, as it is necessary to find an appropriate place to which they can be discharged; this results in increased boarding of other patients within the ED. Consequently, end of life care can result in increased crowding within an ED.

At the same time, increased crowding due to other causes can result in a decreased quality of end of life care that is provided in the ED. Although in a perfect world the ED may not be the ideal location for end of life care, the reality is that a large amount of end of life care is taking place there. When their medical condition deteriorates, it is not unusual for patients with terminal diseases to come to the ED. In addition to the ethical imperative to treat those in medical need, EMTALA- as discussed above- mandates that patients presenting to the ED with a medical crisis be treated or stabilized. At the same time, care for patients at the end of their lives is complex, in that it necessarily deals with addressing the physical, social, emotional, and spiritual components of a patient’s disease. This requires a multidisciplinary approach, including input from multiple medical specialties, nursing, chaplains, social work, and others. Other common needs of patients at the end of life include financial issues, timely access to healthcare providers, issues surrounding care giving, and mental health needs- all of which are difficult to fulfill in the emergency department.14 Because of the constant flow of new patients needing emergency care, patients are often temporarily ignored when new emergency patients have a need for urgent treatment. Thus, it becomes even more difficult to deal with these complex end of life issues, and quality of care suffers.

What Does the Future Hold?
Some efforts are being made to both improve end of life care in the ED and, at the same time, reduce ED crowding. There has been a relatively recent movement to increase education in palliative care in medical schools,15 as well as to increase the number of palliative care rotations in physician residencies.16 In addition, there is a new hospice and palliative medicine subspecialty of emergency medicine, which may lead to better management of end of life care in the ED.17 A key step to take in addressing end of life care associated crowding in the ED would be to encourage more of those patients who are nearing the end of their lives to prepare advance directives, and to discuss their wishes with their family and personal healthcare provider. This would prevent some unnecessary ED visits, as well as ensure that the patient's wishes are carried out if they are taken to the ED. Ultimately, the problem of boarding will have to be addressed head-on by healthcare administrators and policymakers. Without such action, crowding and substandard end of life care in EDs will continue.


1 Institute of Medicine, Hospital-Based Emergency Care: At the Breaking Point (2006).
2 American College of Emergency Physicians, ACEP Policy Statements: Crowding, available at http://www.acep.org/Content.aspx?id=29156&terms=crowding (last visited February 18, 2011).
3 Richard W. Derlet, John R. Richards & Richard L. Kravitz, Frequent Overcrowding in U.S. Emergency Departments, 8 Academic Emergency Medicine 2 (2001).
4 United States Department of Health and Human Services, Centers for Disease Control and Prevention, Staffing, Capacity, and Ambulance Diversion in Emergency Departments: United States, 2003-04, available athttp://www.cdc.gov/nchs/data/ad/ad376.pdf (last visited March 2, 2011).
5 42 U.S.C. § 1395dd(a).
6 42 U.S.C. § 1395dd(b)(1)(A).
7 42 U.S.C. § 1395dd(b)(1)(B).
8 American Hospital Association, Trendwatch Chartbook 2007, available at http://www.aha.org/aha/trendwatch/chartbook/2007/07chart3-7.pdf (last visited February 18, 2011).
9 Bruce Siegel, The Emergency Department: Rethinking the Safety Net for the Safety Net , Health Affairs (24 March 2004).
10 American College of Emergency Physicians, ACEP Policy Statements: Definition of Boarded Patient, available at http://www.acep.org/Content.aspx?id=75791 (last visited February 18, 2011).
11 United States General Accounting Office (now known as the Government Accountability Office), Hospital Emergency Departments: Crowded Conditions Vary Among Communities and Hospitals, available at www.gao.gov/new.items/d03460.pdf (last visited February 18, 2011).
12 American College of Emergency Physicians , Emergency Department Crowding: High-Impact Solutions, available at www.acep.org/WorkArea/DownloadAsset.aspx?id=50026 (last visited February 18, 2011).
13 John C. Moskop, David P. Sklar, Joel M. Geiderman, Racquel M. Schears & Kelly J. Bookman, Emergency Department Crowding, Part 1-Concept, Causes, and Moral Consequences, 53 Annals of Emergency Medicine 5 (2009).
14 Corita R. Grudzen, Lynne D. Richardson, Matthew Morrison, Elizabeth Cho & R. Sean Morrison, Palliative Care Needs of Seriously Ill, Older Adults Presenting to the Emergency Department, 17 Academic Emergency Medicine 11 (2010).
15 See, e.g. Daniel P. Sulmasy, James E. Cimino, M. K. He &William H. Frishman, U.S. Medical Students' Perceptions of the Adequacy of their Schools' Curricular Attention to Care at the End of Life: 1998–2006, 11 Journal of Palliative Medicine 5 (2008).
16 See, e.g. Aaron M. Olden, Timothy E. Quill, Donald Bordley & Susan Ladwig, Evaluation of a Required Palliative Care Rotation for Internal Medicine Residents, 12 Journal of Palliative Medicine 2 (2009).
17 Other participating physician specialty boards include: Anesthesiology, Family Medicine, Internal Medicine, Pediatrics, Physical Medicine and Rehabilitation, Psychiatry and Neurology, Obstetrics and Gynecology, Radiology, and Surgery. For more information, visit the American Academy of Hospice and Palliative Medicine's website at www.aahpm.org.

The ABA Health eSource is distributed automatically to members of the ABA Health Law Section . Please feel free to forward it! Non-members may also sign up to receive the ABA Health eSource.