FOREIGN RELATED LITERATURE You know how long you will wait to ride your favorite roller-coaster at the

amusement park, and the number of minutes youll spend standing until the next train pulls into the subway station. Soon, you may know how long you will have to wait for care at your local hospitals emergency department. Emergency Department (ED) overcrowding is a common medical care issue in the United States and other developed nations. One major cause of ED crowding are holding patients waiting in the Emergency Room (ER) for inpatient unit admission where they block critical ED resources.Emergency physicians are committed to providing highquality emergency care as quickly as possible to all patients.A federal report last year found that patients who need to be seen in 1 to 14 minutes are being seen in twice that timeframe (37 minutes) (GAO, 2009). An ambulance is diverted every minute in the United States, delaying care for critically ill patients.The gridlock in emergency departments is caused by "boarding," not by too many patients with routine minor problems. In this section of the literature review, the causes, effects and indicators to measure overcrowding are explored. One study in particular examined the relationship between crowding and wait time. Results demonstrated that increase in the number of patients in a crowded ED dramatically affected the patients wait time (McCarthy et al, 2009). The downstream effects of internal ED and hospital processes are manifested in the upstream process of wait times. In a Canadian national survey on overcrowding, the study found 79% of ED directors were in agreement that overcrowding resulted in prolonged ED wait times (Bond, Ospina et al. 2007). Therefore the results from the literature survey on overcrowding will also be applicable to ED wait times. An overwhelming number of studies have attributed overcrowding to the number of inpatients occupying an ED bed (Fatovich, Nagree et al. 2005; Bond, Ospina et al. 2007; Ospina, Bond et al. 2007; Asplin 2008). Other causes of overcrowding have been associated with the lack of inpatient beds (Derlet and Richards 2000; Bond, Ospina et al. 2007) or intensive care beds (Schull 2002), shortage of ED nursing staff (Derlet and Richards 2000), lack of available on-call specialty consultants (Derlet and Richards 2000; Bond, Ospina et al. 2007) and increased complexity and acuity of patients (Derlet and Richards 2000; Derlet 2002; Bond, Ospina et al. 2007). The consequences of overcrowding have many deleterious effects on patients, staffing and quality of patient care. During overcrowding, occupancy levels are high and fewer beds are available for medical staff to treat new patients, which impedes patient flow. As a result, without available stretchers, incoming patients must wait for prolonged periods for an assigned treatment area (Derlet and Richards 2000; Bond, Ospina et al. 2007; Asplin 2008). Delayed medical interventions results in prolonged pain and suffering as well as the risk of poor patient outcomes (Bond, Ospina et al. 2007) and patient safety (Derlet and Richards 2000). Unfortunately, when some EDs are overcrowded and cannot receive another critically ill patient, they place an ambulance diversion status which redirects emergency medical services (EMS) patients to another, possibly further ED (Derlet and Richards 2000; Bond, Ospina et al. 2007). Most patients who are transported in EMS vehicles are acutely ill and require timely medical interventions (Redelmeier, Blair et al. 1994; Pham, Patel et al. 2006). Why do patients wait in emergency departments? Everyone who comes to an emergency department will be seen, regardless of the ability to pay or insurance status. Studies show the reasons patients wait include: 1.) A triage process, which means critically ill patients are seen first and less critically ill

patients must wait. In most cases, a triage nurse will assess the severity of a patients condition upon arrival, based on symptoms; personal and medical history; and vital signs, such as body temperature, heart rate and blood pressure. 2.) Boarding of patients. Hundreds of emergency departments have closed in the United States. At the same time, the number of emergency department visits have increased to 119.2 million in 2006 (up from 110.2 million in 2004). Many of the remaining hospitals lack capacity, which means critically ill or injured patients may have extended stays in the emergency department until hospital beds become available. This practice is known as "boarding," and it is a major factor in overcrowding. Boarding also contributes to ambulance diversion and limits a hospitals ability to meet periodic surges in demand, such as those from disasters.3.) On-call physician shortages. Emergency physicians are available 24 hours a day, 7 days a week, but other medical specialists, such as neurosurgeons, cardiologists and orthopedic surgeons, provide "on-call" backup services as needed. An increasing number of these specialists are not available due to frivolous lawsuits, increasing premiums, inability to obtain insurance and inadequate reimbursement.4.) Local crises and disasters. In an emergency department, many patients may arrive at once, needing immediate medical care. This can happen when multiple motor vehicle crashes occur and during natural disasters or local epidemics. Long waits can affect patient outcomes. Patients may get tired of waiting and leave. Some patients may wait longer than optimal, but emergency departments work hard to make sure the sickest patients are seen first and all patients are seen in a timely manner.In 2008, 200 emergency physicians said they personally knew of patients who had died because of the practice of "boarding," or patients waiting for their inpatient hospital beds.In 2006, the Institute of Medicine released reports, which found timeliness of care to be "a growing concern" that could "result in protracted pain and suffering and delays in diagnosis and treatment." How much time should you expect to be in an emergency department? If you have a minor illness or injury, and the emergency department isnt crowded, you may wait 1 to 2 hours to see a physician. If you require extensive diagnostic tests, your visit may be longer because it will take time to obtain the results. If an emergency physician needs to consult with other medical specialists, your wait may be extended. If you need to be admitted to the hospital, you may wait until an inpatient bed is available. In 2007, U.S. emergency patients spent an average of 4 hours and 5 minutes in the emergency department, a 5-minute increase from the previous year (Press Ganey Associates, 2009). South Dakota had the shortest waits (165 minutes) and Utah had the longest waits (385 minutes). Almost 400,000 patients waited 24 hours or more; patients admitted to the hospital, or referred for drug or alcohol treatment, were in the emergency department about 6 hours on average. (Press Ganey Associates, 2009). Do uninsured people and patients with routine problems increase waiting times? Patients with minor problems do not contribute significantly to long wait times. An August 2006 study published in the Annals of Emergency Medicine found that "reducing the number of low-complexity emergency department patients is unlikely to reduce waiting times for other patients." According to Dr. Jesse M. Pines and Dr. Zachary F. Meisel (Time Magazaine, 2011), another major cause of crowding and diversion is ER boarding, which occurs when patients spend long periods of time in the ER waiting to go to inpatient beds. Boarding ties up the ER so that doctors and nurses can't see new patients, which in turn prolongs everyone's waiting times and causes the ER to become overcrowded and divert ambulances.

While the JAMA (Journal of the American Medical Association) study results put very real mortality numbers on diversion, many previous studies have also found crowding and diversion to be dangerous. Nevertheless, some hospitals have been reluctant to fix it. The time it takes to get treated at emergency rooms in the U.S. is on the rise, but hospitals are trying new methods to reduce the wait. About 14% to 27% of all emergency-room visits could take place at urgent-care centers or retail clinics, according to another study published last September in Health Affairs. Its perfectly rational to go to the emergency room for comparatively minor conditions if you cant access care elsewhere, if the primary-care physician cant get you in, or you cant get off work for the day, said Robin M. Weinick, lead researcher and a senior social scientist at Research and Development Corporation. (Anya Martin, 2011). Redirecting patients to other caregivers In Milwaukee County, according to Dr. Paul Coogan, Wis., 48% of the 363,377 emergency-department visits last year were non-emergent, emergency-department medical director at Aurora Sinai Medical Center in Milwaukee. He quoted that theres a lot of non-urgent, non-emergent use of ERs because, lets face it, were pretty quick, open 24-7, board-certified in emergency medicine, and because of law, we have to see everybody who shows up. To meet federal legal guidelines, all arriving patients at Aurora-Sinais emergency department are seen and triaged by a physician, nurse practitioner or physician assistant, he said. If a patient is found to have a non-emergent issue, he is educated about the appropriate use of the emergency room to reduce unnecessary future visits and then sent to a scheduler to make a follow-up appointment with an appropriate primary-care provider.