The Emergency Department: A Safety Net or a Buffer?

Navigating the emergency department over the past years has been akin to constructing the Eiffel Tower with toothpicks. It's a precarious balancing act, a constant struggle against the odds. The seemingly insurmountable issue of patient boarding in the ED looms like a storm cloud, not just here but darkening the skies of healthcare systems worldwide. How did we end up in this labyrinth of uncertainty? Will we ever rediscover the path to stability?

To understand the problem, I think it's helpful to understand how things have evolved since the start of the COVID-19 pandemic. The US healthcare system was already experiencing strain before the pandemic. Patient boarding in the ED happens when patients are admitted to the hospital though physically stay in the ED. The American College of Emergency Physicians had begun studying ED boarding several years before the COVID-19 pandemic. However, it came to a head during the pandemic from the acute stress the health crisis placed on emergency departments.

To me, ED boarding is an important metric of health system stress because of the nature of the emergency department. The ED has become the literal front door of the health care system. Positioned between a dysfunctional outpatient system and an inpatient system that struggles to find appropriate places for patients to go after they leave the hospital. As a society, we have collectively decided that the emergency department should be everything for anyone at any time. It hasn't been an intentional decision but rather an evolution of a system over time, molded by human behavior and political decisions. It's an example of accidental design.

We think of emergency medicine as a safety net but often confuse that idea with what it has become: a buffer. A buffer is something you plan into the design of a system, something that is built to respond when that system becomes overloaded. We haven’t intentionally chosen the emergency department to play this role but have accepted it as a default. How can an emergency department adequately respond to patients with emergencies when it's acting as a buffer for the rest of the health care system? The ED should be a safety net, catching what the rest of the system couldn’t. The ED shouldn’t be the default buffer, though; the place the rest of the system allows to problem solve for it. We have to do a better job designing better buffers for the health care system that don't rely on the emergency department to serve that role. We must create resiliency within the system to allow it to bend at other points without breaking.

The resiliency of a system is created by adequate slack. There’s a reason firefighters at a firehouse often spend portions of their day cooking, cleaning and doing things other than fighting fires - so they can respond when the fire alarm does ring.

How might we create the proper slack in the health care system that allows the emergency department to continue to respond to patients experiencing unforeseen medical problems? We need to find ways for other components of the more extensive system to serve the buffer role. We need to think creatively about how we use the physical space in our hospitals. We need to build new front doors to the health care system that get patients the care they need without relying on the emergency department when it’s not an emergency.