Your excellent exposé about acutely overcrowded emergency rooms leaves out another, significant, contributing etiology: a chronic, severe shortage of psychiatric hospital beds and other, less-intensive mental health treatment resources that could and ought to accept and treat patients. Psychiatric treatment has long been woefully underfunded: non-government hospitals lose money on psychiatric inpatient care, and tight government budgets (coinciding with an unwillingness to increase revenues) translate into insufficient state (or other) government-run hospitals. In Vermont, my home state, hospitals are small; yet at any time, up to a dozen psychiatric patients end up being boarded in ERs for up to weeks at a time. Over the years, community hospital ERs have created quasi-psych units for these patients, but these rely on ER staffs, with occasional psych consultations, to provide oversight for these patients. Until third party payers, governments, and society at large appreciate that dollars up front for psychiatric care translate into substantial financial savings (not to mentioned improved psychiatric and general medical well-being), this problem is only going to get worse.
As a retired physician I am very familiar with the problems you cite. There is one simple fix that would make an immediate difference: moving to fully staffed 7 days a week hospital and outpatient services. It makes no sense that expensive hospital facilities like OR’s, cath labs, and endoscopy suites sit idle on weekends while patients are parked in scarce hospital beds awaiting their procedures. It is equally absurd that large primary care and multispecialty practices limit weekend outpatient services, forcing patients into urgent care centers and ER’s. The logistic challenges and costs are real but not insurmountable, and the resulting efficiencies will translate into lower expenses, higher profits, better outcomes and greater patient satisfaction. Walmart manages to keep its stores fully open all year round. Why can’t Humana, Sentara, HCA, Kaiser-Permanente and the VA do the same?
One can’t help but think of how miserable an experience flying has become in this country to “maximize revenue”, and how any slight perturbance multiplies the misery many times over far out of proportion to the cause. Travelers lose time and money, but the same disconnected and heedless greed now apparently governs our medical care - and lives are lost rather than just time and money. Not sure a more dramatic change isn’t needed of removing the profit motive from healthcare altogether.
In Massachusetts, a for profit health care system--Steward--is on the brink of failure and all of the other hospitals are full with no capacity.
Personally, as a primary care physician, I find my local (Massachusetts adjacent) ER's are so overwhelmed and too many patients are being sent or go because of no access to primary care appointments when ill. I've called over to triage when the ED misses important information due to the crunch.
The Boston Globe has been publishing data on how long patients are in the ED, and it's far too long.
Just this past week, a friend went to the ER. He had elevated BP and left shoulder pain. An ekg was done, reviewed, and he was sent to sit in the waiting room. No one came to check on him. No VS redone. Hours passed. He left.
He’s 87 years old with a cardiac hx of MI, stent, and chronic afib. Ironically his own cardio was the one taking call that night but the ER never reached out.
This is considered one of the best hospitals in DC.
So, let me qualify myself with my professional history before you read my response. I have been an RN for 20+ years, a tech and a secretary and a hospital volunteer, a Paramedic/EMT for 14 years, Flight Nurse for 2 years. I have the alphabet behind my name and worked in urban and rural settings from California to Oklahoma, in hospitals and clinics. The C-Suite is killing people...
Let's start with EMS in this discussion. Paramedics and EMTs are told to "bring everyone in". Doesn't matter if it is appropriate or not. They are skilled and trained to weed out the non-emergent and due to money, we tell them they are "not qualified" to make no-haul decisions anymore. (You can't bill a no-haul). They are sitting in halls and driveways delaying care to REAL EMERGENCIES because the hospital can't handle it.
Front-line triage in major emergency departments should be staffed and run by at least mid-levels. You will meet your EMTALA guidelines with your immediate medical screening exams and again, weed out the non-emergent to a section of the ER with lower acuity staff.
Put RN’s back in the physician’s offices. The well-meaning secretary, CNA, or med aide should not be directing patients over the phone for anything. I know they are cheaper, but they are not ultimately helping the bottom line.
Set up booths in large ER lobbies with vital sign machines, have capable patients sit in them, and get a screening with a licensed provider from anywhere, while the ones screaming in pain can be dealt with by personnel. The patient will feel safe being in a staffed ER if something is acutely emergent. (Most patients who come in are scared because they just don’t know what’s going to kill them and what won’t.)
QUIT REQUIRING EXTENSIVE MEDICAL HISTORY SCREENING IN THE ER TRIAGE AREA!!!! It is important, but EPIC has way too many options that hospitals want to use. No one cares about your Tetanus status when you have chest pain, or suicidal ideation for a 3-year-old.... please take the time at your institution to clean this up.
Medicare/Medicaid should require ALL ERs to provide a specific mental health area. Especially for holds. Staff should be certified in that and paid appropriately.
Hospitals are staffing ERs with the most inexperienced warm body they can find. New nurses should ALWAYS start on the floor. NEVER ER or ICU. Seasoned nurses can work more efficiently in the ER, moving patients through. We spend way too much time training and re-training, restarting IVs, double checking meds and administrations, and emotionally stabilizing the NEW nurse who has just witnessed life's most horrific moments. Seasoned ER nurses are not expendable, we are one of the most important departments and assets to your institution. (I’m looking at you, elective surgery).
I have been in love with emergency medicine since starting in 1995, and it is a massive train wreck. We are not killing patients, the C-suites are killing the morale of the providers who no longer want to ride the train over the edge.
My university medical center, which is located in a very affluent city, is always completely full. No beds, no icu beds, surgical schedule packed. The ERs are bad, but so is the rest of the system. We are constantly out of all kinds of fundamental supplies and drugs. Recently we were rationing pulmonary artery catheters for cardiac surgery patients. I believe the entire US medical system is capacity limited to an amazing degree. It's appalling.
Primary care is also in crisis with many leaving the field due to unreasonable work loads for poor reimbursement. Many people no longer have a primary care doctor and even if they do it is hard to get a timely appointment or call back. Back when your own doctor was able to see you the same day for acute needs, we kept more people away from the emergency room. When you're scared, worried, hurt and google tells you it could be something life threatening, you go to the hospital. If you talk to the team that knows you the plan often avoids the hospital.
As both a hospital administrator and physician, I need to point out that most hospitals in the US are losing large sums of money. Even the non profits. The cost of staff has gone up tremendously. Not sayin they aren't worth it but the numbers are huge. Reimbursement from all insurances continues to decline. Using regulatory sticks to fix this problem will result in fewer hospitals surviving. We've already lost too many hospital beds. Part of the ER problem is that many people in our ERs dont need an ER. They need urgent care or just plain outpatient care. But as you point out we cant turn them away. Ever. For any reason. Thats a regulation. but it takes resources from taking care of truly ill patients contributing to the ER crisis. And yes to respond to a reply below, it does come down to dollars.
Good luck with all this. The medical "industry" is like a used-car salesperson - focused on the money, not the client (patient). And the U.S. populace continues to tolerate this abomination.
Truth is, I've seen this phenomenon for literally years. The "24 hour clinic" at Ben Taub, the public hospital in Houston is famous for the fact that the name both identifies that it's always available, and that the wait time is on the order of, or exceeds 24 hours. I've worked codes in the waiting room, as well as moving patients expeditiously back to the treatment areas, because they arrested waiting for care.
In another setting, nearly 40 years ago, I had pediatric patients waiting for beds either on the floor, or (rarely) the PICU because we were at capacity, or didn't have nursing staff to accept them in the middle of the night.
Back then, it was usually driven by staffing patterns, as we couldn't get nurses, although at Ben Taub, they were at capacity the day they opened the new (now old) hospital. I suspect politics limited the size of the expansions, but I didn't get involved in those. The pediatric hospital was affiliated with a large faith-based denomination and their expansion (eventually happened) required significant vertical expansion as well as claiming land that'd been dedicated to other offices, parking, etc. before they finally were large enough to reduce such waits, long after my time there ended.
The pandemic has seen a renewed focus on these issues. Unfortunately, another aspect is that hospitals are increasingly being run by corporate entities rather than medical professionals: The focus is on profit, not necessarily patient best outcomes.
I don't have a solution. I'm out of the game directly, and merely an observer looking in. But this is a problem I've seen before, firsthand.
Thank you for this article. As you indicated, this lack of a buffer existed prior to the pandemic. When COVID first hit the scene, I remember saying that this was going to be a disaster for any number of reasons not the least of which was the hospital system. It infuriates me that this reality wasn't talked about at all when it came to how vigorously we had to try to mitigate the pandemic. Our system has a hard time handling a bad flu season. Even if COVID had been only as bad as the seasonal flu we would have been in serious trouble both in the short and long term. We simply COULD NOT afford another virus, much less one that is still much worse than the flu. The situation was are in now was 100% predictable from day one of the pandemic. Now many people are acting like they're surprised, and I can't blame them because nobody in a leadership role got up and told the truth about the consequences of allowing COVID to spread as far as we have and mutate over and over.
It's ultimately a political problem. A certain party backed by a certain electorate has made one thing certain: No gubbermint gonna control mah medical! And there you have it. Reform has been rejected by the electorate in favor of obscene profits, death and disability through neglect, and unaffordable care. This is what we want, and this is what we will have. That certain electorate overwhelmingly rejected vaccination. They'd rather die and they did. They pretty much want the same for all of us. Between disinformation, apathy and disenfranchisement of legitimate voters by a certain party, I frankly see no way out of this problem.
I disagree about hospitals not having an incentive to fix this. They get paid primarily by diagnosis (DRG) and do not get paid extra when patients stay in beds because they have nowhere to go. They lose money on the artificially long hospital stays. However, they don’t have a way to produce home care availability or TCU beds to discharge people to. Government needs to step up and reimburse better for TCU and LTC and increase training of CNA and vital staff.
This is a direct result of allowing monopoly for-profit companies run our hospitals. Some of these companies actually own and manage the hospitals and some are huge insurers that drive down prices they pay regardless of impact on the well being of society.
Your excellent exposé about acutely overcrowded emergency rooms leaves out another, significant, contributing etiology: a chronic, severe shortage of psychiatric hospital beds and other, less-intensive mental health treatment resources that could and ought to accept and treat patients. Psychiatric treatment has long been woefully underfunded: non-government hospitals lose money on psychiatric inpatient care, and tight government budgets (coinciding with an unwillingness to increase revenues) translate into insufficient state (or other) government-run hospitals. In Vermont, my home state, hospitals are small; yet at any time, up to a dozen psychiatric patients end up being boarded in ERs for up to weeks at a time. Over the years, community hospital ERs have created quasi-psych units for these patients, but these rely on ER staffs, with occasional psych consultations, to provide oversight for these patients. Until third party payers, governments, and society at large appreciate that dollars up front for psychiatric care translate into substantial financial savings (not to mentioned improved psychiatric and general medical well-being), this problem is only going to get worse.
As a retired physician I am very familiar with the problems you cite. There is one simple fix that would make an immediate difference: moving to fully staffed 7 days a week hospital and outpatient services. It makes no sense that expensive hospital facilities like OR’s, cath labs, and endoscopy suites sit idle on weekends while patients are parked in scarce hospital beds awaiting their procedures. It is equally absurd that large primary care and multispecialty practices limit weekend outpatient services, forcing patients into urgent care centers and ER’s. The logistic challenges and costs are real but not insurmountable, and the resulting efficiencies will translate into lower expenses, higher profits, better outcomes and greater patient satisfaction. Walmart manages to keep its stores fully open all year round. Why can’t Humana, Sentara, HCA, Kaiser-Permanente and the VA do the same?
One can’t help but think of how miserable an experience flying has become in this country to “maximize revenue”, and how any slight perturbance multiplies the misery many times over far out of proportion to the cause. Travelers lose time and money, but the same disconnected and heedless greed now apparently governs our medical care - and lives are lost rather than just time and money. Not sure a more dramatic change isn’t needed of removing the profit motive from healthcare altogether.
In Massachusetts, a for profit health care system--Steward--is on the brink of failure and all of the other hospitals are full with no capacity.
Personally, as a primary care physician, I find my local (Massachusetts adjacent) ER's are so overwhelmed and too many patients are being sent or go because of no access to primary care appointments when ill. I've called over to triage when the ED misses important information due to the crunch.
The Boston Globe has been publishing data on how long patients are in the ED, and it's far too long.
It's a crisis. thank you for this post.
Just this past week, a friend went to the ER. He had elevated BP and left shoulder pain. An ekg was done, reviewed, and he was sent to sit in the waiting room. No one came to check on him. No VS redone. Hours passed. He left.
He’s 87 years old with a cardiac hx of MI, stent, and chronic afib. Ironically his own cardio was the one taking call that night but the ER never reached out.
This is considered one of the best hospitals in DC.
So, per usual, the issue is the almighty dollar?
So, let me qualify myself with my professional history before you read my response. I have been an RN for 20+ years, a tech and a secretary and a hospital volunteer, a Paramedic/EMT for 14 years, Flight Nurse for 2 years. I have the alphabet behind my name and worked in urban and rural settings from California to Oklahoma, in hospitals and clinics. The C-Suite is killing people...
Let's start with EMS in this discussion. Paramedics and EMTs are told to "bring everyone in". Doesn't matter if it is appropriate or not. They are skilled and trained to weed out the non-emergent and due to money, we tell them they are "not qualified" to make no-haul decisions anymore. (You can't bill a no-haul). They are sitting in halls and driveways delaying care to REAL EMERGENCIES because the hospital can't handle it.
Front-line triage in major emergency departments should be staffed and run by at least mid-levels. You will meet your EMTALA guidelines with your immediate medical screening exams and again, weed out the non-emergent to a section of the ER with lower acuity staff.
Put RN’s back in the physician’s offices. The well-meaning secretary, CNA, or med aide should not be directing patients over the phone for anything. I know they are cheaper, but they are not ultimately helping the bottom line.
Set up booths in large ER lobbies with vital sign machines, have capable patients sit in them, and get a screening with a licensed provider from anywhere, while the ones screaming in pain can be dealt with by personnel. The patient will feel safe being in a staffed ER if something is acutely emergent. (Most patients who come in are scared because they just don’t know what’s going to kill them and what won’t.)
QUIT REQUIRING EXTENSIVE MEDICAL HISTORY SCREENING IN THE ER TRIAGE AREA!!!! It is important, but EPIC has way too many options that hospitals want to use. No one cares about your Tetanus status when you have chest pain, or suicidal ideation for a 3-year-old.... please take the time at your institution to clean this up.
Medicare/Medicaid should require ALL ERs to provide a specific mental health area. Especially for holds. Staff should be certified in that and paid appropriately.
Hospitals are staffing ERs with the most inexperienced warm body they can find. New nurses should ALWAYS start on the floor. NEVER ER or ICU. Seasoned nurses can work more efficiently in the ER, moving patients through. We spend way too much time training and re-training, restarting IVs, double checking meds and administrations, and emotionally stabilizing the NEW nurse who has just witnessed life's most horrific moments. Seasoned ER nurses are not expendable, we are one of the most important departments and assets to your institution. (I’m looking at you, elective surgery).
I have been in love with emergency medicine since starting in 1995, and it is a massive train wreck. We are not killing patients, the C-suites are killing the morale of the providers who no longer want to ride the train over the edge.
My university medical center, which is located in a very affluent city, is always completely full. No beds, no icu beds, surgical schedule packed. The ERs are bad, but so is the rest of the system. We are constantly out of all kinds of fundamental supplies and drugs. Recently we were rationing pulmonary artery catheters for cardiac surgery patients. I believe the entire US medical system is capacity limited to an amazing degree. It's appalling.
Primary care is also in crisis with many leaving the field due to unreasonable work loads for poor reimbursement. Many people no longer have a primary care doctor and even if they do it is hard to get a timely appointment or call back. Back when your own doctor was able to see you the same day for acute needs, we kept more people away from the emergency room. When you're scared, worried, hurt and google tells you it could be something life threatening, you go to the hospital. If you talk to the team that knows you the plan often avoids the hospital.
As both a hospital administrator and physician, I need to point out that most hospitals in the US are losing large sums of money. Even the non profits. The cost of staff has gone up tremendously. Not sayin they aren't worth it but the numbers are huge. Reimbursement from all insurances continues to decline. Using regulatory sticks to fix this problem will result in fewer hospitals surviving. We've already lost too many hospital beds. Part of the ER problem is that many people in our ERs dont need an ER. They need urgent care or just plain outpatient care. But as you point out we cant turn them away. Ever. For any reason. Thats a regulation. but it takes resources from taking care of truly ill patients contributing to the ER crisis. And yes to respond to a reply below, it does come down to dollars.
Good luck with all this. The medical "industry" is like a used-car salesperson - focused on the money, not the client (patient). And the U.S. populace continues to tolerate this abomination.
Truth is, I've seen this phenomenon for literally years. The "24 hour clinic" at Ben Taub, the public hospital in Houston is famous for the fact that the name both identifies that it's always available, and that the wait time is on the order of, or exceeds 24 hours. I've worked codes in the waiting room, as well as moving patients expeditiously back to the treatment areas, because they arrested waiting for care.
In another setting, nearly 40 years ago, I had pediatric patients waiting for beds either on the floor, or (rarely) the PICU because we were at capacity, or didn't have nursing staff to accept them in the middle of the night.
Back then, it was usually driven by staffing patterns, as we couldn't get nurses, although at Ben Taub, they were at capacity the day they opened the new (now old) hospital. I suspect politics limited the size of the expansions, but I didn't get involved in those. The pediatric hospital was affiliated with a large faith-based denomination and their expansion (eventually happened) required significant vertical expansion as well as claiming land that'd been dedicated to other offices, parking, etc. before they finally were large enough to reduce such waits, long after my time there ended.
The pandemic has seen a renewed focus on these issues. Unfortunately, another aspect is that hospitals are increasingly being run by corporate entities rather than medical professionals: The focus is on profit, not necessarily patient best outcomes.
I don't have a solution. I'm out of the game directly, and merely an observer looking in. But this is a problem I've seen before, firsthand.
Thank you for this article. As you indicated, this lack of a buffer existed prior to the pandemic. When COVID first hit the scene, I remember saying that this was going to be a disaster for any number of reasons not the least of which was the hospital system. It infuriates me that this reality wasn't talked about at all when it came to how vigorously we had to try to mitigate the pandemic. Our system has a hard time handling a bad flu season. Even if COVID had been only as bad as the seasonal flu we would have been in serious trouble both in the short and long term. We simply COULD NOT afford another virus, much less one that is still much worse than the flu. The situation was are in now was 100% predictable from day one of the pandemic. Now many people are acting like they're surprised, and I can't blame them because nobody in a leadership role got up and told the truth about the consequences of allowing COVID to spread as far as we have and mutate over and over.
It's ultimately a political problem. A certain party backed by a certain electorate has made one thing certain: No gubbermint gonna control mah medical! And there you have it. Reform has been rejected by the electorate in favor of obscene profits, death and disability through neglect, and unaffordable care. This is what we want, and this is what we will have. That certain electorate overwhelmingly rejected vaccination. They'd rather die and they did. They pretty much want the same for all of us. Between disinformation, apathy and disenfranchisement of legitimate voters by a certain party, I frankly see no way out of this problem.
I disagree about hospitals not having an incentive to fix this. They get paid primarily by diagnosis (DRG) and do not get paid extra when patients stay in beds because they have nowhere to go. They lose money on the artificially long hospital stays. However, they don’t have a way to produce home care availability or TCU beds to discharge people to. Government needs to step up and reimburse better for TCU and LTC and increase training of CNA and vital staff.
This is a direct result of allowing monopoly for-profit companies run our hospitals. Some of these companies actually own and manage the hospitals and some are huge insurers that drive down prices they pay regardless of impact on the well being of society.