It has been an interesting few days as the hospital I work in has been in the news for overcrowding. There sometimes feels like there’s a disconnect between overcrowding and patient safety. On one hand, the international evidence repeatedly shows that ED overcrowding has a negative effect on patient outcome, with increased morbidity and mortality. On the other hand, we are all working in busy EDs, and many patients are getting timely, appropriate care from hard-working staff in spite of these pressures. We are hanging on, doing our best, etc, etc.
The disconnect is because while overcrowding does increase patient risk, it doesn’t change the outcome for every patient. The best way to explain this is by the speed limit analogy.
Imagine a road where the speed limit is 80km/h. It has been decided that 80km/h is as fast as you can drive before the risk of driving on that road becomes unacceptable. There will be times where people on the road are going at 100km/h or 120km/h. Not everybody speeding will have an accident, in fact most won’t. But going faster does increase the risk of an accident, and the faster the speed, the more dangerous it becomes. Yes, someone can have an accident driving at 60km/h but it is much less likely, and when it happens under the speed limit, the outcome is better.
In other words:
Imagine an ED with 8 cubicles. It has been decided that 8 cubicles is as many patients as you can manage before the risk of managing patients in that ED becomes unacceptable. There will be times where there will be 10 or 12 patients in your 8-cubicle ED. Not every patient in an overcrowded ED will have an incident, in fact most won’t. But overcrowding does increase the risk of an incident, and the worse the overcrowding, the more dangerous it becomes. Yes, a patient can have an incident with only 6 patients in the ED but it is much less likely, and when it happens under ED capacity, the outcome is better.