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Message from the MGH

A look at the complicated causes of ER overcrowding.

Summer 2008
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When we feel the squeeze of a heart attack, or we’re in a car accident, or one of our children spikes a fever in the middle of the night, we expect an emergency room bed to be open and at the ready. Too often, it’s not.

In this issue of Proto, we examine the complicated causes of ER overcrowding and report how hospitals across the country are coping. Though the dedicated doctors and nurses who staff ERs have become resourceful at delivering extraordinary care under less-than-ideal conditions, when the system becomes overly stressed, issues of safety and quality of care lurk just beneath the surface.

Like other hospitals, the Massachusetts General Hospital has taken steps to ease its ER crunch. We have implemented an initial screening protocol so patients can see a physician right away; opened an observation unit with beds to accommodate those who have less severe problems and are likely to be discharged within 24 hours; and installed a bed-tracking system that ensures that any available bed anywhere in the hospital can be filled without delay. Though these measures have helped, they only nibble around the edges of the problem. Any long-term fix will have to involve looking far beyond the ER.

Alasdair Conn, our chief of emergency medicine, calls his department the canary in the coal mine. Jam-ups in the ER often foreshadow capacity problems at other vulnerable pressure points—inpatient units, operating rooms, recovery areas. Hospital services are like dominoes: Reach the tipping point, and everything falls.

Even when every inpatient bed is occupied, patients keep coming through the ER’s doors. About one in three will be admitted to the hospital. While these patients wait in the ER for a bed, other patients are upstairs undergoing procedures in the operating rooms, and many of them will need a bed as well. But if none is available, the recovery room, too, will become clogged with patients who have nowhere to go. And backups in recovery cause delays in the OR. Such hospital gridlock, truth be told, is not all that uncommon.

Yet there’s only so much that can be done within a single ER within a single hospital. ER overcrowding, in fact, is not a local or regional problem; it is a national public health crisis. We need a concerted, collective effort from hospitals, insurance companies, the government and entire communities to figure out how to mend health care’s fraying safety net.

Peter L. Slavin, M.D.
Massachusetts General Hospital
David F. Torchiana, M.D.
CEO and Chairman
Massachusetts General Physicians
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