in the United States, with only 20% of them in urbanareas.8 Urban areas are most affected by overcrowdingand therefore should be housing the majority of urgent carecenters. There should be a joint effort between health careproviders and state and federal officials to allocate fundingfor the development of more urgent care centers in urbansettings. A second issue is the uneducated public. Manypeople do not know what an urgent care center is or whatservices it has to offer. If people cannot be seen at their pri-mary care physician’s practice, they either are referred tothe emergency department by their primary clinician orbelieve that the emergency department is their only optionfor care. In addition to increasing the number of urgentcare centers, funding must be allocated to educating thepublic and advertising the resources of urgent care centers.If urgent care centers are readily available to communitiesand people understand their role and advantages, patientswill use this resource and defer the cost and long wait timesin the emergency department.

The crisis of ED overcrowding has a dismal future,with access to primary care expected to worsen over thenext several years. By 2020, there is an expected shortageof 45,000 primary care physicians. To further compoundthis, by 2014, approximately 32 million people will beinsured and required to have primary care clinicians. Theemergency department is already working at maximumcapacity and cannot absorb more patients who are unableto find other sources of care. Urgent care centers are a pieceof the solution. Urgent care centers have the capability tomanage patients who have non–life-threatening emergen-cies. They offer a more cost-effective use of care and havethe potential to absorb 30% to 50% of ED patients. How-ever, a serious effort needs to be made to provide moreurgent care centers in urban areas and educate commu-nities about their resources. If solutions are not taken ser-iously, the national crisis of ED overcrowding is going toresult in catastrophic outcomes.—Stephanie Borkowski,BSN, RN, Member, Philadelphia Chapter, Clinical NurseII, Emergency Department, Hospital of the University of Penn-sylvania, Philadelphia, PA; E-mail: stephanie.borkowski@uphs.upenn.edu

doi:10.1016/j.jen.2011.12.009

REFERENCES1. Graham J, Aitken ME, Shirm S. Correlation of measures of patient

acuity with measures of crowding in a pediatric emergency department.Pediatr Emerg Care. 2011;27(8):706-9.

2. Cunningham PJ. What accounts for differences in the use of hospitalemergency departments across U.S. communities? Health Aff. 2006;25(5):324-36.

3. Institute of Medicine. IOM report: the future of emergency care in theunited states health system. Acad Emerg Med. 2006;13(10):1081-5.

4. Howard MS, Davis B, Anderson C, Cherry D, Koller P, Shelton D.Patients’ perspective on choosing the emergency department for nonur-gent medical care: a qualitative study exploring one reason for over-crowding. J Emerg Nurs. 2005;31(5):429-35.

5. Kennedy J, Rhodes K, Walls CA, Asplin BR. Access to emergency care:restricted by long waiting times and cost and coverage concerns. AnnEmerg Med. 2004;43(5):567-73.

6. Koziol-McLain J, Price DW, Weiss B, Quinn AA, Honigman B.Seeking care for nonurgent medical conditions in the emergencydepartment: through the eyes of the patient. J Emerg Nurs. 2000;26(6):554-63.

7. Milbrett P, Halms M. Characteristics and predictors of frequent utiliza-tion of emergency services. J Emerg Nurs. 2009;35(3):191-8.

8. Urgent Care Association of America. The case for urgent care. http://www.ucaoa.org/docs/WhitePaperTheCaseforUrgentCare.pdf. AccessedNovember, 2011.

9. Weinick RM, Burns RM, Mehrotra A. Many emergency departmentvisits could be managed at urgent care centers. Health Aff. 2010;29(9):1630-6.

10. Weinick RM, Bristol SJ, DesRoches CM. Urgent care centers in theU.S.: findings from a national survey. BMC Health Serv Res. 2009;9(79):1-8.

11. Mehrotra A, Hangsheng L, Adams J, et al. The costs and quality of carefor three common illnesses at retail clinics as compared to other medicalsettings. Ann Intern Med. 2009;151(5):321-8.

ED Crowding and Throughput More than Just an

ED Problem

Dear Editor:The November 2011 article “Transforming an Emer-

gency Department: From Crisis to Excellence”1 presentedone emergency department’s process for improving keyquality indicators related to ED performance. Althoughthe ideas presented in the article certainly are importantprocesses to improve ED efficiency, the content of the arti-cle perpetuates the concept that patient throughput is onlyan emergency department process.

Assid1 stated that patient boarding in the emergencydepartment was rampant, with many patients being dis-charged home from the emergency department after a24-hour stay. The article did not present any actions takenby the hospital to work on inpatient throughput issues,which are a main barrier to ED throughput. Accordingto Howell et al.,2 traditional approaches to improvethroughput that only target the emergency departmenthave failed to relieve the issue.

Clearly, ED crowding and throughput are more thanjust an ED problem. More actions must be taken by facil-ities’ administration and inpatient units to solve the ever-growing crowding and throughput problems that wreckour emergency departments. One action my own facility

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implemented is that an inpatient charge nurse must comesee all ED holds hourly until the patient is moved to theinpatient unit.—Kevin Manning, BSN, RN, CEN, Directorof Emergency Services, Medical Center of Arlington, Arlington,TX; E-mail: kevin.manning@hcahealthcare.com

doi:10.1016/j.jen.2011.12.004

REFERENCES1. Assid P. Transforming an emergency department: from crisis to excel-

lence. J Emerg Nurs. 2011;37(6):537-40.

2. Howell E, Bessman E, Kravet S, Kolodner K, Marshal R, Wright S. Ac-tive bed management by hospitalists and emergency department through-put. Ann Intern Med. 2011;149(11):804-10.

International Membership

Dear Editor:I found myself nodding in agreement as I read the arti-

cle “The Legacy Grows: ENA is International.”1 As a nursein the United Kingdom, I am often asked why I am amember of an American organization. My reply is that itis an emergency nursing organization.

Having worked in both the United Kingdom and Amer-ica, I have concluded that although accents may be differentand health service resources with which to provide emergencynursing care may vary, there is a common passion for whatwe, as nurses, do. Patients around the world have the sameanatomy, physiology, and underlying conditions. Ill healthis a universal concern, as well as an individual one. Patientsaspire to be cared for by educated, skilled, and competent staffwhilst family, irrespective of location, demand the highestlevel of care for their loved ones.

Just one small point though. In Table 11 you list Scot-land as a separate country to the United Kingdom. Scot-land is part of the United Kingdom (which is made upof England, Scotland, Wales, and Northern Ireland). Ifyou list Scotland in its own right, then England (not theUnited Kingdom) should also be listed. In the footballWorld Cup, there is no way I would support Scotland; Iam 110% behind England!!!

Thank you for your article highlighting internationalmembership. I also firmly believe that differences should beacknowledged, but as a profession, we are stronger when weunite over a shared purpose.—Alison Day, MSc, PGCert, BSc(Hons), RGN, RN, Senior Lecturer in Emergency Nursing,Coventry University, United Kingdom; E-mail: hsx482@coventry.ac.uk

doi:10.1016/j.jen.2011.11.018

REFERENCE1. King D, Bonalumi N. The legacy grows: ENA is international. J Emerg

Nurs. 2011;37(6):584-6.

Priority Preparedness Issues

Dear Editor:I applaud the efforts of Foley and Durant1 to increase

awareness of the numerous screening requirements oftenplaced on the triage nurse, particularly when these screeningtools affect patient throughput negatively and when they maynot be warranted. Another concerning trend in triage is theuse of advanced protocols or standing medical orders. Thereis no doubt that these tools can increase patient throughput,increase patient satisfaction, and place valuable diagnosticinformation in the hands of the physician.2-4 However,although advanced protocols are exciting and can improvepatient care, we must not forget to provide the basic care thatis within our practice. All too often nurses carry out standingorders while forgetting to provide basic comfort measuressuch as alleviating pain with ice orelevation.

Additionally, in some cases the use of standing ordersmay delay a patient’s access to an independent practitionerfor the Medical Screening Examination (MSE).5 TheEmergency Medical Treatment and Active Labor Act(EMTALA) specifically prohibits delays in the MSE toinquire about the individual’s ability to pay for services.6

However, any delay could be perceived as a violation ofEMTALA. The rationale for the MSE is to determine ifa medical emergency exists.7 The nurses trying to providethe best possible care may opt to hold patients in the triagearea to obtain laboratory samples or send patients to radi-ology in an effort to complete these standing orders, while aphysician and a bed in the treatment area are available. Forpatients who must wait because of a lack of availablebeds, standing orders are entirely appropriate.—EdwardB. Winslow, BA, BSN, RN, CEN, Member, Austin ENA,Clinical Quality and Patient Safety Manager, EmergencyDepartment, University Medical Center Brackenridge, Hutto,TX; E-mail: ebwinslow@seton.org

doi:10.1016/j.jen.2011.11.009

REFERENCES1. Foley AL, Durant J. Let’s ask that out front: health and safety screenings

in triage. J Emerg Nurs. 2011;37(5):515-6.

2. Lyons M, Brown R, Wears R. Factors that affect the flow of patientsthrough triage. Emerg Med J. 2007;24(2):78-85.

3. Hadly N. Triage: meeting the needs of today in a busy ED. Top EmergMed. 2005;27(3):217-22.

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