As an ER nurse I can offer insight on this problem from firsthand personal experience. Here are a some hard truths:
1) Overcrowding is only a symptom of the larger disease, which is inappropriate use of the Emergency Department. Obviously, illegal immigrants using ERs as their primary healthcare provider are obviously a much bigger problem in in CA, NM, TX and AZ than in WA. So it varies wherever you go. But statistically (at least in my neck of the woods), roughly 80 percent of the people who misuse the ER are Americans who have good health insurance. Americans on government entitlement programs and Americans who think that they won't have to wait to be seen if they take little Johnny to the ER for his stuffy nose are also to blame.
2) Any hospital administration worth its salt would design and build for future capacity based on projected population growth over the next ten to twenty years. In addition, you have to "build in" the ability for the ER to accomodate sudden surges in patient numbers due to mass casualty incidents (bus accidents, fires, explosions, etc.) and natural disasters- especially if the hospital is in an area prone to natural disasters.
3) You have to staff the hospital in a way that can accomodate the rising number of patients. You can't hire more nurses if they don't exist. There aren't enough nursing instructors to train the people who want to become nurses. Tens of thousands of applicants are turned away from nursing schools every year. And due to the recession, hospitals are a little skittish about hiring new nurses right now. That will probably reset itself soon once the hospitals come to their sense (and the patients demand it), because the need for nurses will continue to grow.
4) From an ER perspective, "improving efficiency and patient flow" must start with improving what we call "throughput." Usually, the reason departments are overcrowded is because they are full of patients who are simply waiting for disposition to units upstairs, transfer to other hospitals, or who are on "Psych hold." As hard as we try, we cannot make the receiving units or receiving hospitals accept the patients if there are no beds to put them in or nurses to take care of them- or if receiving doctors don't want to assume responsibility for their care. This is the biggest problem regarding ER overcrowding. Unfortunately, that problem won't change for quite a long time.
Anyway, there's my $0.02 for you.
Your #4 is a big problem down here on the border, too. The ER simply cannot move patients from the ED to MedSurg in a timely manner because the beds aren’t there.
THANK YOU, THANK YOU, THANK YOU!!!!!
In our city, they made the ridiculous projection that they would need fewer beds, not more, when planning on merging the two main hospitals in town. Yeah, I said that right, fewer not more. Then they built the second biggest ER in the state. Unfortunately, it’s not attached to the second biggest hospital. It was a recipe for major bottleneck. Now with the recession, there is no way they can increase beds.
I have a co-worker who works in a walk-in clinic that is slated to close soon. People come in who have medi-cal, but have never chosen their primary care doctor. So when they need refills, they go to the ER or walk-in clinics. They don’t know what medicines they take, names or doses or what.
It is total cluelessness on the part of people.