Hospitals assailed for Emergency Department crush, causing long, risky waits for patients

ACEP-300x98Almost three dozen leading groups representing a range of doctors, specialists, and other health workers have called on the Biden Administration to deal urgently with the long-running but increasing and dangerous practice of hospitals allowing their emergency care facilities to be overwhelmed because they also are parking patients waiting for rooms and treatment.

This “boarding” crisis, already at breaking points for many exhausted ER staffs, will worsen and imperil patients even more if the nation gets hit — as growing indicators suggest is occurring — with a “tripledemic,” a choking load of coronavirus, flu, and other respiratory infections serious enough to require hospitalization.

The American College of Emergency Physicians (38,000 members), has been joined by the American Medical Association, the American Nurses Association, American Academy of Emergency Medicine (8,000 members) and groups representing family doctors, allergists, anesthesiologists, radiologists, osteopaths, psychiatrists, and many others in a recent letter to the administration, reporting:

“Boarding has become its own public health emergency. Our nation’s safety net is on the verge of breaking beyond repair; EDs are gridlocked and overwhelmed with patients waiting – waiting to be seen; waiting for admission to an inpatient bed in the hospital; waiting to be transferred to psychiatric, skilled nursing, or other specialized facilities; or, waiting simply to return to their nursing home. And this breaking point is entirely outside the control of the highly skilled emergency physicians, nurses, and other ED staff doing their best to keep everyone attended to and alive.

“Any emergency patient can find themselves boarded, regardless of their condition, age, insurance coverage, income, or geographic area. Patients in need of intensive care may board for hours in ED beds not set up for the extra monitoring they need. Those in mental health crises, often children or adolescents, board for months in chaotic EDs while waiting for a psychiatric inpatient bed to open anywhere. Boarding doesn’t just impact those waiting to receive care elsewhere. When ED beds are already filled with boarded patients, other patients are decompensating and, in some cases, dying while in ED waiting rooms during their 10th, 11th, or even 12th hour of waiting to be seen by a physician. The story recently reported about a nurse in Washington who called 911 as her ED became completely overwhelmed with waiting patients and boarders is not unique – it is happening right now in EDs across the country, every day.”

The expert blast against ER boarding spells out its dire consequences for patients:

“There is ample evidence that boarding harms patients and leads to worse outcomes, compromises to patient privacy, increases in medical errors, detrimental delays in care, and increased mortality. The Joint Commission identifies boarding as a patient safety risk that should not exceed 4 hours, yet many of the responses to the [American College of Emergency Physician’s] call for stories cite boarding times much longer than that as an almost routine occurrence; 97% of stories with times provided cited boarding times of more than 24 hours, 33% over one week, and 28% over 2 weeks.”

The experts explain that the law bars hospitals from turning away patients who need emergency care. But with increasing health worker burnout (especially tied to the coronavirus pandemic), staff reductions and departures (especially among nurses), and the need for ERs to work 24/7, it can be a struggle for emergency triage to occur. Even when it does, a cascade of challenges then occur as hospitals try to find space to admit patients.

The admissions ordeal is complicated, the doctors write, by multiple factors. In areas outside of the ER, hospitals may be constrained by laws requiring staffing levels, notably nurse-to-patient ratios that cannot be exceeded. Administrators also must juggle and square up admissions from the ER with other patients seeking care — including lucrative, scheduled, and complex procedures or treatment. Space is already spare for treating youngsters and patients requiring mental health care, especially youthful psychiatric cases.

Hospital ERs, as a result, are jammed not only with patients requiring emergency care but with those waiting — in halls, improvised holding areas, and even lobby spaces. This is bad for care and patients.

It also takes a toll on public and private emergency response services, the experts say. They note that ambulance and EMS teams too often get burdened by spending long hours waiting for overwhelmed ER doctors and staff to see patients and to take formal responsibility for them. Earlier crises involving ER care have made it harder for hospitals to formally declare themselves so overloaded that they can divert patients to other facilities.

Not good.  In my practice, I not only see the harms that patients suffer while seeking medical services, but also the  clear benefits they can reap by staying healthy and far away from the U.S. health care system. It is, according to research conducted in pre-coronavirus pandemic times, fraught with medical errorpreventable hospital acquired illnesses and deaths, and misdiagnoses.

That said, we all are one bad wreck, injury, or illness away from needing emergency treatment at hospitals — medical services beyond the capacities of convenient clinics or nearby urgent care centers. When we need ER attention, it is unacceptable that we or our loved ones won’t access it in the timely, efficient, effective, safe, and excellent way that not only we, but also medical providers would wish.

It won’t be easy to resolve the ER boarding problem, because, as the experts told the administration, parts of it go to fundamentals of the very way the U.S. health care system operates. It is the priciest on the planet, with our expense for it running more than $3.5 trillion annually and with hospitals taking up a third of the spending. Though this is a sizable chunk of the nation’s gross national product, hospitals have great sway in running their own businesses — notwithstanding their frequent bleats about over regulation. We’ve allowed fewer owners and operators of hospitals. And we don’t tell them what kind of places they should be — with too many of them becoming big, shiny palaces, jammed with the most expensive equipment available and providing the most costly and duplicative services possible.

The pandemic showed how, when push comes to shove, U.S. hospitals are not set up to provide the care their communities require. Sure, they and every other capitalist enterprise should make a profit. But do we really want market forces only to decide whether our sick or injured youngsters, our ailing seniors, or our teens and young adults challenged with mental illnesses sit for hours, days, or even longer in ERs waiting for treatment? We should heed the alarms from emergency departments or be prepared for dire results.

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