A special session of Congress was convened 35 years ago to inform lawmakers and the public about the stories of patients left dead 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 was born: every individual who comes to the emergency department (ED) must give Medical screening evaluation and appropriate stabilization.this Codify the ED under federal lawas a gateway to hospital-based care in the United States
In its ideal form, ED is tailored to rapidly identify life- and limb-threatening acute illnesses and injuries. For the majority of patients, no such dangerous pathology exists. For a small subset of the sickest patients, our core mission is resuscitation care. We then serve as a flexible acute diagnostic and treatment center ending with discharge or hospitalization.
But what if there are no free beds upstairs on the inpatient side? As most of us have seen, the preferred solution for hospitals is to pile up patients waiting in the ED until a room becomes available. This is what we call “boarding” and is an ever-present threat to our role in resuscitation care for the sickest patients. Over time, our work environment becomes chaotic.
Patients are currently waiting hours, daysand occasionally week in the ED. It’s like asking a teacher to take in a whole new class of students when last year’s class hasn’t finished yet.
New data from two recently published studies jam network open Record what patients, nurses, and doctors already know. It means the embankment has broken. This system collapsed under the weight of urgent medical needs.
By the end of 2021, more than 1 in 10 ED patients in the worst-hit hospitals leave it aloneHalf of the sickest patients in the department — those requiring hospitalization — waited over 9 hours for hospital beds. More and more patients are stationed in the corridors. Patients needing sensitive tests, patients with highly contagious respiratory viruses, and elderly sepsis patients who have to endure bright hallway lights through the night.
The problem isn’t just the physical space, it’s the staff.Nurses crushed under the weight of profit-driven staffing crisis Production period, should care for both inpatients and new patients. In practice, in many cases there is no limit to the staffing ratio of ED nurses. On the medical floor, one nurse may be responsible for her 4-5 patients. Two patients in the ICU. In ED, one nurse is often asked to cover her 10 or more patients. Some critically ill patients are “hospitalized” but waiting for her ICU bed in the ED, so the safety or sustainability of this arrangement has not been considered.
a Recent research The American College of Emergency Physicians (ACEP) invited ED physicians to share what happened as a result of boarding for ED. Patients with cerebral hemorrhages, hip fractures and even necrotizing genital infections are being treated. waiting room Because the ED doesn’t even have beds in rooms or hallways.
Multiple doctors share patient stories die in the waiting room The emergency services were so overwhelmed that I had to wait hours to see a doctor.
Why aren’t hospitals ready to receive patients?
ED boarding is not simply a matter of too many ED patients or inefficient ED staff. Hospital-wide staffing shortages, declining nursing facility capacity, and scheduling of “office hours” for inpatient specialty services all lead to inefficient patient flow within the hospital, ultimately backing up the ED. cause
But perhaps the most significant obstacle to solving ED boarding is the financial unwillingness of hospitals to fix it.
a Recent commentary in the New England Journal of Medicine identified “medical economic inconsistencies” as one of the main factors in boarding. It’s better business for hospitals to keep medical floors close to capacity and prioritize beds for surgical patients. bring in more money, do not leave a buffer of empty rooms available for the predictable surge of ED patients (every Monday afternoon). On Sunday, he said, if the beds on the second floor were more than 90% occupied, hospital revenues might be optimized, but dangerous ED traffic jams are inevitable.
Despite decades of academic research indicate dangerThe only standard set by the Centers for Medicare & Medicaid Services (CMS) for ED boarding is Recommended Maximum boarding time is 4 hours (well over in good weather). There are no mandatory reporting requirements. In 2016, CMS introduced his second metric. It’s an option for hospitals to report boarding times as part of their quality measurements. In 2021, CMS will spontaneously Reported boarding times were not up to crisis levels. Deprecated metric, concluded that ED boarding is not a problem. Of course, it’s very likely that when the hospital reached crisis levels, they simply chose not to report that data.
We ask HHS to work with CMS to articulate the ED boarding problem and publish a multi-pronged approach to identifying solutions. We recommend up-to-date, immediate updates, and public reporting from hospitals on waiting room times, boarding times, and percentage of patients leaving unseen.These measures are more important than simple occupancy measures released to date, representing more frequent and dangerous traffic jams. Additionally, an anonymized reporting mechanism should be created to allow healthcare providers to share staffing ratios. The commission should prepare a report for Congress that includes detailed data on emergency hospital admissions and the stories of medical workers about the tragedies they have seen. Transparency about hospital readiness is an essential first step.in combination with the right regulatory mechanism and financial incentives can encourage the use of flexible capacity and cooperation among various health service organizations to mitigate at-risk conditions during periods of surge in demand for emergency care.
A crisis is underway. Will policy makers and health system leaders take notice?
Alexander T. Janke, MD, MHS, He is a Fellow of the National Clinicalician Scholars Program at VA Ann Arbor Healthcare System and the University of Michigan Institute for Healthcare Policy and Innovation. Jennifer Tsai, MD, MEd, I am a resident emergency physician at Yale University School of Medicine. Kristen Pantagani, MD, PhD, He is an emergency resident at Yale School of Medicine and a Yale Emergency Scholar.
