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Figure: ED boarding, LWBS rates, crowding
Current levels of emergency department boarding are making it impossible for many hospitals to meet the intent of the Emergency Medical Treatment & Labor Act (EMTALA), according to two new studies by Yale researchers. (JAMA Netw Open. 2022;5[9]:e2233964; https://bit.ly/3yCiTjx; 2022;5[9]:e2233708; https://bit.ly/3yJxaeC.)
Alexander Janke, MD, an emergency physician and a visiting research scientist at the Yale School of Medicine and the lead author of the studies, said the data documented unprecedented growth in rates of ED boarding and of patients who left without being seen. The research paints a clear picture of a widespread and increasing level of crowding in America's EDs, which the investigators said is a crisis that puts patient safety and access to care at risk.
Dr. Janke and colleagues found in their first study that boarding times exceeded the four-hour limit recommended by the Joint Commission when hospital occupancy rates reached 85 percent, something the study showed to be quite common. In fact, the median ED boarding time was 6.58 hours in the study, conducted between January 2020 and December 2021. Boarding times also worsened throughout this period, outpacing occupancy rates.
They found in the second study, conducted from January 2017 to December 2021, that the median rate of patients leaving without being seen nearly doubled from 1.1 percent to 2.1 percent. That rate was as high as 10 percent by the end of 2021 at the worst performing hospitals. Both studies used aggregated hospital measures available through a voluntary peer benchmarking service offered by the electronic health record vendor Epic from more than 1200 hospitals.
“I can tell you from experience that at some hospitals, the left without being seen [LWBS] rate can even reach 20 percent,” Dr. Janke said. “One in five people at the hardest-hit hospitals walk out the door after spending 12 to 24 hours waiting for care.”
It's an experience with which most emergency physicians can identify, he said, adding that “LWBS rates are awful and boarding times are out of control because we come in for our shift and there's somebody there we had admitted the day before. It's a smoldering problem in plain sight: People can't get the standard of care that they deserve and that they have a right to under federal law.”
‘We're in Trouble’
The problem is not ED management, said study co-author Arjun Venkatesh, MD, an associate professor of emergency medicine at the Yale School of Medicine, but a capacity crisis across the entire health care system. “We are putting emergency physicians in an impossible position by holding them responsible for stabilizing every patient who comes in the door but not giving them the space to do it,” he said. “Hospitals are understaffed and length of stay has gone up, but that's just the beginning. The roots of the problem lie beyond the hospital, as they have fewer and fewer places to discharge patients. There isn't enough capacity in skilled nursing facilities and rehabilitation hospitals, and there aren't enough home health nurses. We are in a total acute care capacity crisis in this country.”
Harms that result from excess ED boarding and LWBS rates are diffuse and spread across the health care system, Dr. Janke said. Waiting a little too long can lead to oversight, medical errors, and delays in basic care, he explained. “You can imagine older folks waiting longer to get cleaned up after soiling themselves, and those harms just compound.”
Dr. Janke recounted a story about a patient who waited for more than 12 hours in the ED to be seen for a serious skin and soft tissue infection. The patient slept in the waiting room overnight, and when Dr. Janke finally saw him, he said he had almost walked out a couple of times because he couldn't believe how long it was taking. Dr. Janke told the patient he was glad he had stayed because in just one more day he could have had a life-threatening problem. “That's just one of my personal close calls from a recent shift, but all of us have these stories,” he said.
Dr. Janke urged emergency physicians to advocate for timely, publicly available, and high granularity operational data at the hospital and ED levels so they can tell the public and policymakers whether EDs have the staff, space, and resources to take care of people.
The United States can't educate its way out of this problem, Dr. Venkatesh said, because there won't be enough graduates from medical schools and nursing schools. “We need transformative change in care, so that we can provide better and more effective care with fewer people, such as using automation to remove unnecessary friction points in the system that make health care such a human labor-intensive process.
“Can we use robots to bring samples from the ED to the lab? Can we use telesitters to monitor multiple at-risk behavioral health patients with suicidal ideation at a time, freeing up people to go back to the bedside? Right now, the financial incentives favor nonclinical work over clinical work and people being in the hospital over being at home,” he said. “Until there's a financial advantage to having a nurse working at the bedside instead of doing utilization review, we're in trouble.”
Ms. Shawis a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work atwww.writergina.com.
