The impending storm: COVID-19, pandemics and our overwhelmed emergency departments

Previously, I have written about the national crisis in emergency care [1]. As many of us know, emergency departments (EDs) are being overwhelmed by untenable patient volumes and care requirements. As my prior article titled “A Brewing Storm: Our Overwhelmed Emergency Departments” noted, this problem has been well known for many years and, yet, generally ignored by the lay press and public [1]. In 2006, fourteen years ago, the Institute of Medicine (IOM) warned of this in a report titled “Hospital-Based Emergency Care: At the Breaking Point.” In that report, the IOM noted that EDs were already overwhelmed and that our patient visits per year were significantly increasing [2]. The report stated that patient visits from 1993 to 2003 had grown from 90.3 million per year to 113.9 million per year [2]. Also, the number of EDs had actually decreased and the patients being seen were reportedly sicker [2]. Disaster preparedness was a significant concern and the report noted that most city hospitals were operating at or near capacity and even a multiple car crash would create havoc in most of these EDs [2]. In the years since that report, our volumes have continued to climb. In 2017, a National Hospital Ambulatory Medical Care survey reported ED patient visits reached over 138 million in that year [3]. That was a 21% increase from 113.9 million visits in 2003 and an average annual growth of 1.7% per year. That number represents 42.8% of the entire U.S. population of 329 million [4]. These high volumes and the resulting crowding in the ED do and continue to compromise care. Of note, prior studies have shown that ED crowding is linked to increased patient mortality, decreased patient satisfaction and treatment delays [[5], [6], [7]]. In addition to the daily crowding issues, U.S. disaster preparedness is currently in poor condition. The ED is the frontline medical response to any disaster and, yet, it is already stretched to its limit. Currently, one of the federal government's strategies to deal with a potentially overwhelming catastrophic disaster that outstrips resources is to engage in “crisis standards of care” [8,9]. That is, if overwhelmed, the federal government has advised states to create guidelines for hospitals to allocate scarce resources to save the greatest number of lives [8,9]. Such strategies are to be utilized in only the most dire of situations (e.g., severe pandemic, catastrophic event) in which medical resources are completely outstripped. Our current problem with ED volumes predisposes the system to cross this threshold during a disaster.[truncated]