Bi-Modal Volume Variation and ED Design:
Major Causes of ED Crowding
ED Crowding is a very complex phenomenon that does not lend itself to simple solutions.
It has been studied extensively in the Emergency Medicine (EM) literature and by the federal government
in the April 2009 "Report to the Chairman, Committee on Finance, U.S. Senate." The Government
Accounting Office (GAO) concluded that "articles and subject matter experts have reported a lack
of access to inpatient beds as the main factor contributing to crowding." We agree this is
a profoundly important component of the crowding problem. However, we also believe that there
is an equally important factor that is underreported that needs to be addressed to assure
the successful implementation of any ED solution, the bi-modal variability in ED volume.
Traditionally ED volume has been approached in a flat-line manner, but it is well
known that every ED has a daytime volume and a nighttime volume that are dramatically different.
We staff for this fluctuation, but we have not made accommodations in size or design of EDs to create adequate capacity.
Traditional Flat-Line Approach
Most ED experts and architectural firms that specialize in ED design view ED capacity as an average.
Staffing is adjusted based on volume but ED capacity has not been addressed as a major cause of ED Crowding.
Expert Assumptions
Traditional sizing of EDs nationally is based on these assumptions:
- Acute Bed 2,000 pts/bed/year
- Fast Track 3,000 pts/bed/year
- Fast Track only open 12 hours per day so true productivity is 1,500 pts/bed/year
Designing EDs for the average dooms them to fail for 12 hours per day regardless of sufficient staffing. |
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