Although many U.S. hospitals are aware of the benefits of surgical smoothing, very few have been able to implement it, much to Litvak’s dismay. “ER crowding and patient bottlenecks have to be addressed by the entire hospital,” he says. “That’s what smoothing of elective admissions does.” But many hospitals have trouble pushing through this approach—in large part because it asks surgeons, who may bring in much of a hospital’s revenue, to change their schedules. “It takes determined leadership to make this happen,” says Litvak. “If a CEO isn’t behind it, it’s not going to work.”

In the end, individual hospitals can’t solve the problem of ER crowding on their own, and one IOM report emphasized the need for better regional and statewide coordination of trauma and emergency services. Maryland, for example, has created a central communications center that monitors ER bed availability in real time and can direct ambulances to hospitals with the shortest waits. San Diego and Houston are also testing regional approaches.

Congress, too, may get into the act, with legislation that would provide additional funding for physicians offering emergency care while also requiring hospitals to report publicly their typical boarding times. The heightened accountability might spur further innovation, but some physicians worry about the unintended consequences of a system in which hospitals must improve their performance at all costs. “Time measures could wind up encouraging policies that may not be the right answers,” says Schenkel of Baltimore’s Mercy Hospital.

This remains an intractable problem, says David Hnatow, chief of emergency medicine at University of Texas Health Science Center in San Antonio, whose frustration is echoed bymany of his counterparts across the country. During his 15-year tenure, he has tried every innovation he could come up with to ease overcrowding of the hospital’s 44-bed ER, which must cope with 70,000 annual visits, twice the facility’s intended capacity. He has established observational and transitional patient units, created a special unit for psychiatric patients (a source of special treatment and security problems), appointed a bed czar and instituted an electronic bed-tracking system. He has also worked with the San Antonio public health system to provide alternatives to the ER for patients needing primary care.

“But more and more patients keep walking through the door,” Hnatow says. His hospital, as a Level 1 trauma center, serves a region of 25,000 square miles and must handle a growing population of uninsured patients. “I’m willing to try anything,” he says. “But all the vital signs say we’re still in critical condition, and I don’t know what it’s going to take to get people’s attention and really do something about this crisis.”

  Dossier

1. Future of Emergency Care, Institute of Medicine, 2006. A collection of three comprehensive reports examining the challenges and potential solutions to ER overcrowding.

2. urgentmatters.org. This Website for Urgent Matters, a national initiative funded by the Robert Wood Johnson Foundation and dedicated to easing ER overcrowding, offers valuable reports, Webinars and best-practices information. 

3. “Bursting at the Seams: Improving Patient Flow to Help America’s Emergency Departments,” by M. Wilson, K. Nguyen, The George Washington University Medical Center, 2004 [urgentmatters
.org/reports]. An account of how 10 U.S. ERs developed and tested strategies to reduce patient flow bottlenecks, with varying results.

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