Patients Are Dying In Emergency Department Waiting Rooms
By Alexander T. Janke, MD, MHS, Jennifer Tsai, MD, Med & Kristen Panthagani, MD, PhD
A special session of Congress was called 35 years ago to make lawmakers and the public aware of stories of patients left to die in hospital parking lots for lack of insurance. Around the time of that congressional testimony, called "Equal Access to Health Care: Patient Dumping," a new guarantee came about: that any individual who comes to the emergency department (ED) must be given a medical screening evaluation and appropriate stabilization. This codifies the ED, by federal law, as the front door to hospital-based care in the U.S.
In its ideal form, the ED is well-calibrated for the rapid identification of life- and limb-threatening acute illness and injury. For the vast majority of patients, no such dangerous pathology is present, and for a small subset of the sickest patients, our core mission is resuscitative care. After that, we act as a flexible acute diagnostic and therapeutic center that ends in disposition: discharge or hospital admission.
But what happens when there aren't any open beds upstairs, on the inpatient side? As most of us have seen all too often, hospitals' preferred fix is to have patients pile up, waiting in the ED until rooms open up. This is what we call "boarding," and it is an ever-present threat to our role in the resuscitative care of the sickest patients. As the mismatch between acute care needs and available capacity mounts, our work environment descends to chaos.
Patients are now waiting hours, days, and sometimes weeks in the ED. It's like asking a teacher to take on a whole new class of students when last year's class hasn't left yet.
New data from two studies recently published document what patients, nurses, and doctors already know: the levees have broken. The system has collapsed under the weight of acute care needs.
At the end of 2021, in the hardest-hit hospitals, more than one in 10 ED patients left without care. Half of the sickest patients in the department -- those requiring admission -- waited 9 or more hours for an inpatient bed. More and more, patients are placed in hallways: patients who need sensitive exams, patients with highly infectious respiratory viruses, and elderly patients with sepsis who must endure the bright hall lights through the night.
The problem isn't just physical space -- it's staff. Nurses, crushed under the weight of a profit-driven staffing crisis years in the making, must now care for both admitted boarding patients and new patients. In practice, there are often no limits on staffing ratios for ED nurses. On the medical floor, a single nurse may have four to five patients. In the ICU, two patients. In the ED, a single nurse is often asked to cover 10 patients or more, some critically ill who are "admitted" but in the ED waiting for an ICU bed, without regard for the safety or sustainability of this arrangement.
A recent survey by the American College of Emergency Physicians (ACEP) invited ED doctors to share what they've seen happen as a result of ED boarding. Patients with brain bleeds, hip fractures, and even necrotizing genital infections are being treated in the waiting room because there are no rooms or even hallway beds available in the ED.
Multiple physicians shared stories of patients dying in the waiting room because the ED was so overwhelmed, they had to wait for hours to see a physician.
Why Aren't Hospitals Ready for Patients?
ED boarding is not simply a matter of too many ED patients or inefficient ED staff. Staffing shortages throughout the hospital, reduced capacity at nursing facilities, and "business hours" scheduling of inpatient specialized services all lead to inefficient patient flow through the hospital, ultimately causing a backup in the ED.
But perhaps the most significant roadblock to solving ED boarding is that hospitals are financially disincentivized from fixing it.
A recent commentary identified "misaligned healthcare economics" as one of the primary drivers of boarding. It is better business for hospitals to keep their medical floors near capacity, prioritize beds for surgical patients who bring in more money, and not leave a buffer of open rooms available for predictable surges of ED patients (every Monday afternoon). If more than 90% of beds are full upstairs on Sunday, hospital revenues may be optimized, but dangerous ED gridlock becomes inevitable.
Despite decades of academic work demonstrating the dangers, the only standard set by the Centers for Medicare & Medicaid Services (CMS) on ED boarding is a recommended 4-hour maximum boarding time (we're way past that on a good day), with no mandatory reporting requirements. In 2016, CMS introduced a second metric: an option for hospitals to report boarding times as a part of their quality measures. In 2021, when CMS saw hospitals who voluntarily reported boarding times were not reaching crisis levels, they discontinued the metric, concluding ED boarding was not an issue. Of course, it's highly likely that when hospitals did reach crisis levels, they simply chose not to report that data.
We call on HHS, in cooperation with CMS, to announce a multi-pronged approach to clarifying the problem of ED boarding and identifying solutions. We recommend up-to-date, rapidly-updating, and public reporting from hospitals on waiting room times, boarding times, and rates of patients leaving without being seen. These measures, more so than the simple occupancy measures released to date, are more often representative of dangerous gridlock. In addition, an anonymized reporting mechanism should be created for healthcare providers to share their staffing ratios. This commission should prepare a report for Congress including detailed data on ED boarding as well as stories from healthcare workers on the tragedies they've seen. Transparency on the state of hospital preparedness is an essential first step. In combination with the right regulatory mechanisms and financial incentives, we can incentivize the availability of flexible capacity and cooperation among disparate health services organizations to relieve dangerous conditions during times of surge demand for acute care.
The crisis is ongoing. Will policymakers and health system leaders take note?
Alexander T. Janke, MD, MHS, is a fellow in the National Clinician Scholars Program at the VA Ann Arbor Healthcare System and the University of Michigan Institute for Healthcare Policy and Innovation. Jennifer Tsai, MD, MEd, is an emergency medicine resident physician at Yale School of Medicine. Kristen Panthagani, MD, PhD, is an emergency resident physician and Yale Emergency Scholar at Yale School of Medicine.
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