Lacking big fixes, many hospitals are experimenting with modest approaches, and some have made significant progress with innovations that might be blueprints for other ERs. “Whatever you put in place has to work for your department, because all ERs have different staffs, populations and cultures,” says Stephen Schenkel, chief of emergency medicine at Mercy Hospital in Baltimore, who recently led a coalition of Maryland hospitals that examined ER patient safety. While these tentative solutions may not be universally applicable, they do provide a menu of possibilities that other institutions can use. And they seek to improve a department that is increasingly central to hospitals’ missions. “To a large degree, the crowding is an acknowledgment that ERs offer something the rest of the system doesn’t,” Schenkel says. “They provide access to immediate care.”

In 2001 some 55,000 patients were treated at Strong Memorial’s 59-bed emergency room; by 2007, the total had ballooned to 93,000. “Like many ERs that have experienced growth, we weren’t built to hold 120 to 140 patients at a time,” Schneider says. “There aren’t enough beds, chairs, pillows or even toilets for patients when we’re full.” Even on easier days, the institution has patients not only in the ER but also in the catheterization lab, the surgical recovery room and a holding unit in an area that once housed faculty offices. 

Compounding the problem is the fact that hospitals themselves are often full up, leaving patients who need inpatient beds waiting in the ER. As a result, for many emergency departments, creatively using a range of facilities has been crucial to ensuring that patients get the care they need. One increasingly common tactic is to move admitted patients to hallways of inpatient units. That relieves ER crowding without unduly burdening the floors on which these patients are “boarded.” Peter Viccellio, vice chairman of the department of emergency medicine at Stony Brook University Hospital in New York, has been an advocate of this solution, which he estimates is being tried by some 10% of the nation’s hospitals.

At Stony Brook, which has used the approach since 2001, a maximum of two patients are allowed to board in any other hospital unit. “It reduces the burden on the ER staff and adds only slightly to the work on other floors, where a team of nurses may have to care for 32 patients instead of 30,” Viccellio says. And although the hospital’s 60-bed ER still has patients parked in its hallways, there are now usually only seven or eight rather than twice that number.

As long as they have a privacy screen and a call button, most patients prefer to wait in the quieter hallways of inpatient units, Viccellio says, and studies have shown that these patients generally get beds more quickly than when they’re out of sight in the ER. What’s more, since Stony Brook adopted this innovation, the hospital has never had to divert ambulances elsewhere. Yet many hospitals are unable or reluctant to board patients who come in through the ER in other departments, largely because staff members resist. There are safety issues too. “Suppose something acute happens,” says the MGH’s Conn. “In the ER we’re ready to intervene, but on other floors, physicians and nurses may not be available.”

Though many ER patients may truly need emergency care, others don’t, and William Beaumont Hospital, a 1,061-bed teaching facility in Royal Oak, Mich., now uses a 21-bed observation unit to supplement its 70-bed ER. Patients with less severe conditions—for example, an infection that can be treated with antibiotics—are assigned to the “obs” unit, where their progress can be monitored. “It’s a fantastic alternative,” says Jedd Roe, chair of Beaumont’s emergency department. “The patients we put there have a 90% probability of getting sent home without being admitted to the hospital. That frees up an ER bed.”

Despite this innovation, the ER, which has seen visits increase by more than a third during the past 10 years, still suffers chronic overcrowding. Though the ER also routinely boards admitted patients on inpatient floors, 20 to 30 patients are usually waiting for a bed. “The good news is that they don’t have to wait as long now,” Roe says.