Thirty-three provider groups penned a joint letter to President Joe Biden this week warning of “gridlocked” hospital emergency departments that are threatening patients’ lives and the well-being of shorthanded healthcare workers.
“In recent months, hospital emergency departments (EDs) have been brought to a breaking point. Not from a novel problem—rather, from a decades-long, unresolved problem known as patient ‘boarding,’ where admitted patients are held in the ED when there are no inpatient beds available,” provider associations including the American College of Emergency Physicians (ACEP) and the American Medical Association (AMA) wrote. “While the causes of ED boarding are multifactorial, unprecedented and rising staffing shortages throughout the healthcare system have recently brought this issue to a crisis point.”
The issue of boarding “has become its own public health emergency” for adult and pediatric care alike, the latter of which is being driven by a spike in mental health visits and, more recently, a “triple threat” of flu, COVID-19 and respiratory illnesses that have backed up children’s hospitals.
“If the system is already this strained during our ‘new normal,’ how will emergency departments be able to cope with a sudden surge of patients from a natural disaster, school shooting, mass casualty traffic event or disease outbreak?” the groups wrote.
The letter included a handful of firsthand accounts solicited by ACEP from anonymous emergency physicians describing patients deteriorating or dying “during their tenth, eleventh or even twelfth hour of waiting to be seen by a physician.”
Many of these respondents detailed daily boarding numbers “close to or even exceeding” their total number of ED beds and ad hoc treatments being delivered in ED waiting rooms, if at all.
“High numbers have included last week when our 22-bed emergency department had 35 boarders and an additional 20 patients in the waiting room,” one emergency physician’s account reads. “In addition, we have patients who unfortunately have died in our waiting room while awaiting treatment. These deaths were entirely due to boarding.”
The impact is being felt beyond patients alone. Physicians and nurses “are now facing stresses and moral injury that go well beyond everyday practice” as overcrowding and boarding pile onto the stress and personal safety risks already weighing down these clinicians.
“It is demoralizing to start every patient encounter with profuse apologies for the wait and difficulty they have had to endure just being in our emergency department,” another of ACEP’s anonymous physician accounts reads. “It is heartbreaking to find someone who could be my grandmother languishing in pain for hours before we are finally able to see and evaluate her. We are in a crisis and although we do everything we can to 'MacGyver' solutions to the problem while we are on shift, there is only so much we can do from the ground.”
Nearly two-thirds of physicians reported feeling burned out in 2021, according to AMA, while a third of nurses recently surveyed said they were very likely to leave their jobs in 2022 and cited burnout as a chief reason.
More than 330,000 healthcare providers have already dropped out of the workforce over the course of last year, according to a recent report. With many EDs are currently understaffed, the groups wrote that additional burnout-driven departures “will only increase the insufficiency, forcing their fellow nurses to an even more severe condition and impeding the ability to provide high-quality patient care.”
The provider groups said the causes of increased boarding are “multifactorial” but drew particular attention to “misaligned incentives” within the healthcare industry. Hospitals, they wrote, have a financial benefit to add and dedicate beds to elective admissions while boarding any backlog of nonelective patients in the ED.
“We are treating things like acute appendicitis out of the waiting room with IV fluids and antibiotics, fluids while awaiting [the operating room],” according to an anonymous physician cited in the letter. “We have not canceled any elective surgeries and until last week they were getting inpatient beds before people holding in ED more than 24 hours right after [the post-anesthesia care unit].”
ACEP, AMA and the other groups called on the Biden administration to prioritize the uptick in boarding and, specifically, to call a summit of industrywide stakeholders “to identify immediate and long-term solutions to this urgent problem.”
“All of these [physician] stories paint a stark picture of boarding’s impacts on every aspect of the health care system,” the groups wrote. “Yet it is clear a disproportionate share of that burden is being carried by two key stakeholders—the emergency care team and their patients. At any time, any of our loved ones are just a moment away from becoming one of these patients, and their health and safety will depend on your immediate action to address a system that is heading toward collapse.”