Two new studies paint a bleak picture of emergency departments across the United States.
There are not enough beds to go around and pronounced staffing shortages. As a result, folks may languish in emergency room hallways for hours and leave without seeing a doctor as the skeleton staff tends to patients who are waiting to be admitted. And this situation has only gotten worse during the COVID-19 pandemic.
“The acute care system is in crisis as manifested both by sick patients waiting in the emergency room for limited hospital beds and by patients coming to an emergency room but leaving without care due to prolonged wait times,” said Dr. Alexander Janke, the author of both studies. He is an emergency medicine physician at Hurley Medical Center in Flint, Mich.
This affects everyone, Janke said.
"Everyone needs access to timely and high-quality emergency care, for things like car accidents, heart attacks and strokes. Those most affected are the already hard-hit patients who are underinsured or uninsured, and those in fewer resourced areas, whose limited access to the health care system is further blunted by this crisis," he added.
Turning things around starts with hiring more nurses and creating more room in emergency departments and hospitals and nursing facilities. Changes in how hospitals and doctors get paid for their services are also part of the solution, Janke said.
For the studies, the researchers examined how long patients “boarded” in the emergency department after doctors determined they should be admitted and how often they left before receiving care.
A health care industry group called the Joint Commission recommends that boarding not exceed four hours.
When hospital occupancy topped 85% during the COVID-19 pandemic between January 2020 and December 2021, boarding times exceeded 6.5 hours, compared with 2.4 hours during times when hospitals were less crowded. Boarding times worsened throughout this period, the study showed.
In the second study, the researchers looked at how many people leave the emergency department before even being seen by a doctor, and this rate nearly doubled between January 2017 and December 2021, from 1.1% to 2.1%.
When Janke and colleagues took a deeper dive into data at the end of 2021, they found that 5% of hospitals had more than 10% of patients who entered their emergency departments leave before being seen. That's more than double rates from 2017 and the early part of 2020, the study showed.
"A critical number of American emergency departments are functioning in disaster mode daily with dangerous and uncomfortable wait times," said study author Dr. Ted Melnick, an associate professor of emergency medicine at Yale School of Medicine in New Haven, Conn.
“These waits are not just to get in to be seen but also once admitted to the hospital to get an inpatient bed, [and] as a result, there is a bottleneck to be seen as well, and many patients are leaving without an evaluation,” Melnick said.
This is a crisis, added study author Dr. Arjun Venkatesh, an associate professor and chief in the department of emergency medicine at Yale University.
"Almost everyone needs access to a local emergency room not only for a possible heart attack or after a car crash but even if they have a belly ache or concern for pneumonia,” Venkatesh said. “As the de facto site for acute care, keeping space and staff available to new patients 24/7 is essential."
The two studies were recently published online in JAMA Network Open.
Dr. Gabe Kelen is a professor and chair of emergency medicine at Johns Hopkins University in Baltimore, and a spokesman for the American College of Emergency Physicians. He and his colleagues published a major report on this issue last year in the New England Journal of Medicine Catalyst.
“These two papers really reinforce what we have been saying,” Kelen said. “This is a huge issue that affects the vast majority of hospitals at least some of the time.”
Long waits and overcrowding are more than just an inconvenience, said Kelen, who reviewed the new findings. They are also huge patient safety issues.
“When a hospital is greater than 85% full, you are asking for trouble and it's not unusual to be more than 100% occupied because the vast majority of hospitals need to keep beds full to make ends meet,” he said.
Urgent care centers are popping up everywhere, but they aren't really picking up the slack because they are only options for people with insurance or disposable incomes, Kelen said.
“People who can't afford urgent care go to the emergency department,” he said.
The solution includes staffing up, paying providers what they are worth, and improving access to and payment for telemedicine services, Kelen suggested.
Patience is part of the solution as well, he added.
"The level of experience in emergency departments is extraordinary, but we are not McDonald's," Kelen said. “You are seeing experts who are worth waiting for, but it may take a while and it's not fair to think you will be in and out in 10 minutes.”
Some emergency rooms advertise their wait times so if you are not too sick, check online to see if you can time your arrival, he suggested.
This doesn't mean that you will get subpar care -- especially in a true medical crisis.
“Anyone who is ultra-ultra-ill will be seen immediately, and there are things staff can get going from the waiting room,” Kelen said.
The American College of Emergency Physicians has more on emergency room care and services.
SOURCES: Alex Janke, MD, MHS, emergency medicine physician, Hurley Medical Center, Flint, Mich.; Ted Melnick, MD, MHS, associate professor, emergency medicine, Yale School of Medicine, New Haven, Conn; Arjun Venkatesh MD, MBA, MHS, associate professor, emergency medicine, and chief, section of administration, Yale University, New Haven, Conn.; Gabe Kelen, MD, director and professor, emergency medicine, Johns Hopkins University, Baltimore, Md.; JAMA Network Open, Sept. 30, 2022, online