EMERGENCY DEPARTMENT CROWDING: EXPLORING BIAS AND BARRIERS TO EQUITABLE ACCESS OF EMERGENCY CARE

Abstract

The emergency department (ED) has often been considered the safety net of the American healthcare system. It earned this distinction because every person in the United States has access to a medical screening exam and stabilization at an ED regardless of their ability to pay. Unfortunately, over the past several decades, decreasing numbers of EDs and inpatient beds, coupled with increasing rates of ED usage, has led to crowding of EDs across the country. Crowding leads to unsafe conditions that may increase morbidity and mortality for patients, or cause patients to leave the ED without being evaluated by a physician. Essentially, crowding causes a barrier for patients to access their right to emergency evaluation. The problem of crowding is most pronounced in large urban communities, and these already frequently underserved patients suffer the most from the crowding burden. The main cause of crowding seems to be the boarding of admitted patients in the ED, however many often cite high rates of non-urgent patients presenting to the ED as a cause of crowding. Some have even suggested diverting non-urgent patients to help solve the problem of crowding. I became interested in this topic due to crowding concerns and initiatives to decrease the number of patients who left without being seen at my own institution. As I reviewed relevant research, I became aware of my own misconceptions and noted a trend of literature suggesting non-urgent patients are not the cause of crowding. Drawing on research from many different sources, paired with evaluation based on principles in bioethics, I have come to several conclusions. I believe the systematic diversion of non-urgent patients is unsafe, and that the unequal burden of ED crowding on urban communities represents an unjust barrier in access to care. We must continue to carefully research the demographics of patients frequently presenting to EDs to avoid perpetuating stereotypes about which types of patients are responsible for crowding. We should also look for ways to ease the crowding burden in urban communities. Additionally, we should take a qualitative assessment of our individual communities to determine if there are any particular reasons in our community that people choose to use the ED rather than other healthcare options. I believe these suggestions can be an important addition to the efforts already in motion to help reduce ED crowding and provide equitable access to emergency medical evaluation.