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Sorry—we’re full! Access block and accountability failure in the health care system

Published online by Cambridge University Press:  01 April 2015

Grant Innes*
Department of Emergency Medicine, University of Calgary, Calgary, AB
Correspondence to: Dr. Grant Innes, Department of Emergency Medicine, University of Calgary, 416 12 Street NW, Calgary, AB T2N 1Y8; grant.


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Administration Series
Copyright © Canadian Association of Emergency Physicians 2015 


1. Institute of Medicine Committee on the Future of Emergency Care in the United States Health System. Hospital-based emergency care: at the breaking point. Washington (DC) National Academies Press; 2006, Executive summary available at: (accessed August 10, 2012).
2. Canadian Association of Emergency Physicians Access to acute care in the setting of emergency department overcrowding. CJEM 2003;5:8186.
3. Fatovich, DM, Nagree, Y, Sprivulis, P. Access block causes emergency department overcrowding and ambulance diversion in Perth, Western Australia. Emerg Med J 2005;22:351354, doi:10.1136/emj.2004.018002.
4. American College of Emergency Physicians Task Force on Boarding. Emergency department crowding: high-impact solutions. Available at: (accessed October 25, 2013).
5. Rowe, BH, Bond, K, Ospina, MB, et al Emergency department overcrowding in Canada: what are the issues and what can be done? Technology overview No 21 Ottawa Canadian Agency for Drugs and Technologies in Health; 2006.
6. Hoot, NR, Aronsky, D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med 2008;52:126136, doi:10.1016/j.annemergmed. 2008.03.014.
7. Kellermann, AL. Crisis in the emergency department. N Engl J Med 2006;355:13001303, doi:10.1056/NEJMp068194.
8. Canadian Association of Emergency Physicians. Position statement on overcrowding 2009. Available at: (accessed October 25, 2013).
9. Pitts, SR, Pines, JM, Handrigan, MT, Kellermann, AL. National trends in emergency department occupancy, 2001 to 2008: effect of inpatient admissions versus emergency department practice intensity. Ann Emerg Med 2012;60:679686, doi:10.1016/j.annemergmed.2012.05.014.
10. Moskop, JC, Sklar, DP, Geiderman, JM, et al. Emergency department crowding—barriers to reform and strategies to overcome them. Ann Emerg Med 2009;53:612617, doi:10.1016/j.annemergmed.2008.09.024.
11. Bell, R, Willett, J, Oliver, J.. An Expert Working Group reporting to the Physician Hospital Care Committee, a tripartite committee of the Ontario Hospital Association, the Ontario Medical Association and the Ontario Ministry of Health and Long-Term Care 2006, Improving access to emergency care: addressing system issues.
12. Canadian Institute for Health Information. Access to inpatient beds and patient flow. Available at: (accessed October 26, 2013).
13. Chalfin, DB, Trzeciak, S, Likourezos, A, et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med 2007;35:14771483, doi:10.1097/01.CCM.0000266585.74905.5A.
14. Liew, D, Liew, D, Kennedy, MP. Emergency department length of stay independently predicts excess inpatient length of stay. Med J Aust 2003;179:524526.
15. Richardson, DB. The access-block effect: relationship between delay to reaching an inpatient bed and inpatient length of stay. Med J Aust 2002;177:492495.
16. Krochmal, P, Riley, TA. Increased health care costs associated with ED overcrowding. Am J Emerg Med 1994;12:265266, doi:10.1016/0735-6757(94)90135-X.
17. Hwang, P, Richardson, LD, Sonuyi, TO, et al. The effect of emergency department crowding on the management of pain in older adults with hip fracture. J Am Geriatr Soc 2006;54:270275, doi:10.1111/j.1532-5415.2005.00587.x.
18. Pines, JM, Hollander, JE. Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med 2008;51:15, doi:10.1016/j.annemergmed.2007.07.008.
19. Geelhoed, GC, de Klerk, NH. Emergency department overcrowding, mortality and the 4-hour rule in Western Australia. Med J Aust 2012;196:122126, doi:10.5694/mja 11.11159.
20. Sprivulis, PC, DaSilva, JA, Jacobs, IG, et al. The association between overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust 2006;184:208212.
21. Richardson, DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust 2006;184:213216.
22. Guttmann, A, Schull, MJ, Vermeulen, MJ, Stukel, TA. Association between waiting times and short-term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ 2011;342:d2983 doi:10.1136/bmj.d2983.
23. McCarthy, ML, Zeger, SL, Ding, R, et al. Crowding delays treatment and lengthens emergency department length of stay, even among high-acuity patients. Ann Emerg Med 2009;54:492503, doi:10.1016/j.annemergmed.2009.03.006.
24. Schull, MJ, Vermeulen, M, Slaughter, G, et al. Emergency department crowding and thrombolysis delays in acute myocardial infarction. Ann Emerg Med 2004;44:577585, doi:10.1016/j.annemergmed.2004.05.004.
25. Scheuermeyer, FX, Christenson, J, Innes, G, et al. Safety of assessment of patients with potential ischemic chest pain in an emergency department waiting room: a prospective comparative cohort study. Ann Emerg Med 2010;56:455462, doi:10.1016/j.annemergmed.2010.03.043.
26. Kulstad, B, Kelley, KM. Overcrowding is associated with delays in percutaneous coronary intervention for acute myocardial infarction. Int J Emerg Med 2009;2:149154, doi:10.1007/s12245-009-0107-x.
27. Fee, C, Weber, EJ, Maak, CA, et al. Effect of emergency department crowding on time to antibiotics in patients admitted with community-acquired pneumonia. Ann Emerg Med 2007;50:501509, doi:10.1016/j.annemergmed.2007.08.003.
28. Eckstein, M, Chan, LS. The effect of emergency department crowding on paramedic ambulance availability. Ann Emerg Med 2004;43:100105, doi:10.1016/S0196-0644(03)00747-9.
29. Fatovich, DM, Hirsch, RL. Entry overload, emergency department overcrowding, and ambulance bypass. Emerg Med J 2003;20:406409, doi:10.1136/emj.20.5.406.
30. Barbera, JA, Macintyre, AG, DeAtley, CA. Ambulances to nowhere: America’s critical shortfall in medical preparedness for catastrophic terrorism BCSIA Discussion Paper 2001-15, ESDP Discussion Paper ESDP-2001-07 Boston John F. Kennedy School of Government, Harvard University October 2001.
31. Institute of Medicine. Future of Emergency Care. Hospitalbased emergency care: at the breaking point. Washington (DC) The National Academies Press; 2006.
32. Health Quality Council of Alberta. Review of the quality of care and safety of patients requiring access to emergency department care and cancer surgery 2012.
33. Government Accountability Office. GAO report: crowding continues to occur, and patients wait longer than recommended time frames. April 2009. Available at: (accessed October 25, 2013).
34. Yong, PL, Saunders, RS, Olsen, LA. editors Institute of Medicine The healthcare imperative: lowering costs and improving outcomes: workshop series summary. Washington (DC) The National Academies Press; 2010.
35. Schuur, JD, Venkatesh, AK. The growing role of emergency departments in hospital admissions. N Engl J Med 2012;367:391393, doi:10.1056/NEJMp1204431.
36. Morganti, KG, Bauhoff, S, Blanchard, JC. The evolving role of emergency departments in the United States. Santa Monica (CA) RAND Corporation; 2013.
37. Tang, N, Stein, J, Hsia, RY, et al. Trends and characteristics of US emergency department visits, 1997-2007. JAMA 2010;304:664670, doi:10.1001/jama.2010.1112.
38. Gindi, RM, Cohen, RA, Kirzinger, WK. Emergency room use among adults aged 18–64: early release of estimates from the National Health Interview Survey, January–June 2011. National Center for Health Statistics; May 2012. Available at:
39. Doyal, L. Needs, rights and equity: moral quality in healthcare rationing. Qual Healthc 1995;4:273283, doi:10.1136/qshc.4.4.273.
40. Emanuel, EJ, Emanuel, LL. What is accountability in health care? Ann Intern Med 1996;124:229239, doi:10.7326/0003-4819-124-2-199601150-00007.
41. Robertson, J, Walkom, EJ, Henry, DA. Health systems and sustainability: doctors and consumers differ on threats and solutions. PloS One 2011;6(4):e19222 doi:10.1371/journal.-pone.0019222.
42. Brett, AS, McCullough, LB. Addressing requests by patients for nonbeneficial interventions. JAMA 2012;307:149151, doi:10.1001/jama.2011.1999.
43. Brody, H.. From ethics of rationing to ethics of waste avoidance. N Engl J Med 2012;366:19491951, doi:10.1056/NEJMp1203365.
44. Smith, R, Hiatt, H, Berwick, D. Shared ethical principles for everybody in health care: a working draft from the Tavistock group. BMJ 1999;318:248251, doi:10.1136/bmj.318.7178.248.
45. Shortell, SM, Waters, TM, Clarke, KWB, et al. Physicians as double agents: maintaining trust in an era of multiple accountabilities. JAMA 1998;280:11021108, doi:10.1001/jama.280.12.1102.
46. Davies, HTO, Nutley, SM, Mannion, R. Organizational culture and quality of health care. Qual Health Care 2000;9:111119, doi:10.1136/qhc.9.2.111.
47. Girod, J, Beckman, AW. Just allocation and team loyalty: a new virtue ethic for emergency medicine. J Med Ethics 2005;31:567570, doi:10.1136/jme.2004.009332.
48. Emanuel, EJ, Fuchs, VR. The perfect storm of overutilization. JAMA 2008;299:27892793, doi:10.1001/jama.299.23.2789.
49. Cassel, CK, Guest, J. Choosing wisely: helping physicians and patients make smart decisions about their care. N Engl J Med 2012;307:18011803.
50. Berwick, DM, Hackbarth, AD. Eliminating waste in US health care. JAMA 2012;307:15131516, doi:10.1001/jama.2012.362.
51. Weinstein, MC, Skinner, JA. Comparative effectiveness and health care spending—implications for reform. N Engl J Med 2010;362:460465, doi:10.1056/NEJMsb0911104.
52. Fisher, ES, Wennberg, DE, Stukel, TA, et al. The implications of regional variations in Medicare spending, 2: Health outcomes and satisfaction with care. Ann Intern Med 2003;138:288298, doi:10.7326/0003-4819-138-4-200302180-00007.
53. Welch, WG, Schwartz, L, Woloshin, S. Overdiagnosed: making people sick in the pursuit of health. Boston Beacon Press; 2011.
54. Grady, D, Redberg, RF. Less is more: how less health care can result in better health. Arch Intern Med 2010;170:749750, doi:10.1001/archinternmed.2010.90.
55. Berney, L, Kelly, M, Doyal, L, et al. Ethical principles and the rationing of health care: a qualitative study in general practice. Br J Gen Pract 2005;55:620625.
56. Kelen, G, Kraus, CK, McCarthy, ML, et al.. Inpatient disposition classification for the creation of hospital surge capacity: a multi-phase study. Lancet 2006;368:19841990, doi:10.1016/S0140-6736(06)69808-5.
57. Kelen, G, McCarthy, ML, Kraus, CK, et al. Creation of surge capacity by early discharge of hospitalized patients at low risk for untoward events. Disaster Med Public Health Prep 2009;3(Suppl 1):S17.
58. Darby, M. Health care quality: from data to accountability. Acad Med 1998;73:843853, doi:10.1097/00001888-199808000-00009.
59. Harber, B, Ball, E. Redefining accountability in health care. Managing Change 2003, (Spring) 1322.
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