We will know when we are serious about solving our health care crises when we stop supporting such policies which are nothing more than a monopoly over such shortages to ensure that hospitals profit from them, at the expense of patients.

The status quo is to keep all the admitted patients in the ED, where nursing ratios quickly approach or exceed 1:12. Is it somehow safer to keep all of the admitted patients in the ED hallways in order to maintain nursing ratios on the floors? Viccellios main point is that it makes much more sense to put 1 boarder in each inpatient unit instead of keeping them all in 1 unit (the ED) which has a limited supply of nurses, as well as a steady flow of new patients.

You’re right that the process involves three aspects of input, throughput, and output. However, you oversimplify the issues involving those three processes.

I work in a couple of different places and both of their departments become overcrowded for different reasons.

Viccellio’s study didn’t compare outcomes of ED boarded patients with outcomes of floor hallway patients. It compared patients in inpatient beds versus patients in inpatient hallways. A comparison of outcomes in what we’re trying to measure, including effects on patient flow in the ED and even the effects on hospital income would be a much better way to study the issue. Unfortunately, given the varying acuity of ED patients, the results would likely be difficult to interpret.
Also, the study didn’t (and probably couldn’t) account for the “high maintenance” patients in the ED. Can’t really put vents, drips, monitors, psych patients, ect in a hallway. What do you do when your ED is full of these patients waiting for beds?

What happens when the hospital doesn’t have sufficient staffing for the inpatient beds? Still cram patients on the floors and overwork the available nurses? When mistakes increase, then who gets blamed? Would you be OK with your mom being put in a hallway with two nurses trying to cover (and write electronic notes on) 24 patients? If not, why? What’s the maximum number of patients that should be covered per nurse? What if the patients are high-maintenance?
What happens when nurses become fed up with being overworked and leave for another job. Then there are even fewer staff available to care for patients. Then what?
What happens when six patients register to be seen in a small ED within 30 minutes of each other, the ED only has 6 beds, and 4 of them are already full? You say it doesn’t happen that much. I work in a rural ED part time and I see it happen all the time. Has nothing to do with “boarding”.

But you’re on the right track of at least raising the questions and proposing solutions.

Rand can certainly do more to promote these solutions, and should; and emergency physicians, as front line providers, need to keep pushing from the pit to encourage hospitals to do what they can do: but some of the wider cultural issues around health care that need to be changed in this country will be even more difficult to effect. We will need well regarded physicians to lead this effort, and if you have heard Dr. Kellerman speak, you know he is pretty good at that.

Why “spend more money” to improve the system when there is another solution that costs nothing: Tell the EPs and nurses to see more patients faster, or lose their contract and their job.