Walking into an emergency department (ED) these days can be jarring. Patients lined up in the hallways await care, harried nurses and doctors doing all they can to triage and tend to those patients, and emotions running high all around. Sometimes it’s hard to grasp that this is healthcare in a first-world country. But America’s EDs are suffering the consequences of many adverse factors.

A visit to the ED can drag on for hours. In Florida, for instance, a patient can expect to wait an average of 2 hours, 41 minutes before a doctor sees them. In Pennsylvania, that time extends to just over 3 hours, and in Washington, DC, on average, patients wait for 5 hours and 14 minutes.

At risk are a host of factors, not the least of which is patient care. Delayed treatment, the chances for increased medical errors, and in the older population, there’s an increased risk for mortality when they must spend the night waiting for care.

For the healthcare workers trying to care for these patients, the risks are equally as dire.

“We’re good at taking care of anyone who walks in the door,” said Bruce Lo, MD, chief of emergency medicine at Sentara Norfolk General Hospital and Sentara Leigh Hospital, both in Norfolk, Virginia. “But the work environment has become much more difficult. Frustration and burnout are increasing and that undermines patient care and safety.”

While the issue of ED boarding and its fallout has been building for years, it’s hitting a tipping point today. Healthcare systems nationwide are aware of the problems and are trying a variety of solutions to address them. But just as the trouble didn’t begin overnight neither will the solutions be immediate.

How We Got Here

Many hospitals can draw a straight line to the pandemic as the point of overwhelm, but that served as the straw that broke the camel’s already stressed back.

“The problem stems from a lack of health education in this country,” said Michael Eagan, MD, director of emergency medicine at Hackensack Meridian Old Bridge Medical Center in Old Bridge, New Jersey. “We see people who haven’t been to the doctor in years coming in with routine problems, but then we diagnose advanced diseases. It’s almost a landmine.”

Eagan says that in a nation full of chronic diseases like diabetes, heart disease, and kidney disease, the lack of education is coming to a head. It’s the ED that pays the price.

“This is an underlying factor in the explosion of inpatient bed needs,” he said. “The issue becomes stabilizing people and getting them back out into the community in a way that won’t have them bouncing back in 30 days.”

In the meantime, the lack of available beds starts the back up in the emergency room. “ED boarding is very much a hospital capacity issue,” said Lo. “We have a decreasing number of hospitals around the country, so there are fewer inpatient beds available,” he said. “Since the pandemic, we’ve also had an increase in demand from the aging and medically complicated. They are sicker and more complex patients. The ED is the front door, but the need is for the beds inside.”

Joanna Hiatt Kim, vice president of payment policy at the American Hospital Association agreed with Eagan’s assessment. “It’s a lack of all the parts working together in healthcare,” she said. “The ultimate solution will lie with the healthcare system as a whole.”

Kim points fingers at the insurance industry, among other sources of the broken system.

“We see delays and denials of prior authorization from both Medicare and private insurance,” she said. “So if a patient needs post-acute care, whether in rehab or at home, insurance delays prevent them from leaving the hospital.”

The patient, in turn, stays in a much-needed bed, backing up the ED. There’s also the workforce shortage, writ large. The shortage began showing up during the pandemic, but it continues today. This is at every level of the healthcare system — including downstream at nursing and rehabilitation facilities — and it affect emergency care.

“Everyone points to the hospital itself for the problems and solutions,” said Eagan. “It’s easy to blame those factors, but the bigger question is why do we have so many people coming into the ED and then needing to stay? We don’t have a system that works.”

Possible Solutions

While there’s agreement that addressing the overall broken healthcare system is the necessary solution, hospitals are also looking at ways to tackle ED boarding within their own ecosystem. For the past several years, this has been a big focus at Cooper University Health Care in Camden, New Jersey.

Andrew Nyce, MD, vice chairman of the Department of Emergency Medicine, and Michael Chansky, MD, chairman of the department, have led the effort.

“We’ve had a collaborative effort with all the stakeholders, including nursing, labs, radiology, and administration,” said Nyce. “If we don’t have the engagement and support of the institution’s leaders, we wouldn’t be successful.”

This joint effort has resulted in several process changes throughout the hospital, with the end goal relieving the ED. “Successful hospitals develop strategies to pull patients upstairs,” said Nyce.

Cooper took a two-bucket approach, focusing on what the hospital can do to increase backend throughput and what the ED can do internally to move patients through at a faster rate. As a team, the entire institution has set annual quality goals to manage patient inflow and discharges.

Specifically, these include goals to expedite discharges before noon or 2 PM at the latest. “Every party has an impact on this, and we’ve taken the data to them to demonstrate why they play a role in ED throughput,” said Chansky.

Cooper has created a discharge lounge, for instance. Patients who the ED has discharged no longer wait in the ED for their rides home. The hospital has also figured out ways to perform some services in an outpatient format, such as colonoscopies or heart ultrasounds, further freeing up beds. They have also opened a surgical center in nearby Morristown to handle outpatient surgeries. And the hospital has also opened some services 7 vs 5 days a week.

Cooper has even extended changes out to its local emergency medical service teams, leading to faster turnaround when they arrive at the ED. All told, the various efforts at Cooper have resulted in a decrease in length of average stay by 1 day. In a hospital with 750 beds, that’s a substantial difference.

Likewise, Lo’s Sentara system has taken a multipronged approach to solving ED boarding.

“We’ve worked toward earlier patient discharge by identifying those patients who don’t need to be inpatient to get their continuing care,” he said. “We have social workers, specialists, and case managers all doing rounds together to get patients home safely and quickly.”

The team has also turned to centralized bed management to get better coordination between departments.

“We use technology to predict who can go home, what resources are needed, what staff is needed to help turn beds, and how quickly we can get patients upstairs,” said Lo. “Flow improves when everyone owns it.”

At the end of the day, everyone agrees that the ED troubles begin and end on a systemwide level. But in the meantime, individual hospitals are doing all they can to address the issues.

“There’s no silver bullet to fix things,” said Lo. “Different hospitals have different problems, but we all want quality of care for our patients.”