Crowding in emergency departments (EDs) across the country and around the world has had an impact on care quality. There have been documented increases in patient mortality, medication errors, pain, length of hospital stay, and other negative effects. When an ED is overcrowded, all licensed beds may be occupied, and overflow patients are frequently treated in hallways. In such cases, emergency physicians (EP) are forced to provide care to patients with inadequate nursing support and a lack of privacy, which precludes a thorough history and physical examination. Placing new patients in the waiting room until a licensed ED bed becomes available introduces an additional risk because there is no way to directly observe or monitor patients. Some hospital administrators insist on providing care in the hallways but fail to provide the logistical support required to do so. By emphasizing metrics such as the number of patients seen per hour, some ED staffing groups indirectly force physicians to see patients in unlicensed areas. Patient care in ED hallways is fraught with delays and difficulties in initiating laboratory testing, providing medication, supervising intravenous lines, recording vital signs, monitoring cardiac activity, or responding to new patient symptoms, regardless of the cause. The problem is exacerbated when a physician must simultaneously care for an excess of patients in the hallway and in official ED beds, and extra physicians are frequently unavailable to share the burden. In addition to the risk of poor patient outcomes, physicians are at risk.
In most emergency rooms across the country, patients must wait for several hours before being evaluated, treated, and admitted to the hospital. Far too often, patients end up “boarding” in emergency room hallways while waiting for a hospital bed to become available. According to the Centers for Disease Control and Prevention, two-thirds of American hospitals boarded patients in the ED for more than two hours while waiting for an inpatient bed, affecting approximately 1 in every 5 patients. If you were injured because of medical malpractice or lost a loved one as a result of a preventable medical error, call our office today. Allow an experienced medical malpractice attorney to fight for your rights. At DeFrancisco & Falgiatano, our highly experienced medical malpractice attorneys may be able to help you collect the compensation you deserve. We help clients throughout Upstate New York, with offices in multiple convenient locations. Our extensive experience in the medical malpractice field is reflected in the results we have achieved for our clients.
Boarding has been identified as one of the most serious consequences of ED overcrowding by the American College of Emergency Physicians. Aside from the frustration of seeing a loved one waiting for care in a hallway, patients who are left in the hallways can become confused and disoriented, which are symptoms of delirium.
There is no simple explanation for why hospitals are so overcrowded that boarding has become so common. More than 1,000 hospitals have closed across the country since the mid-1970s due to a lack of profitability, while ED visits have been increasing since the 1990s. Despite this, most U.S. hospitals are only operating at about 65% of their total inpatient capacity, according to data on cdc.gov. How can both statements be correct? One factor is that Medicare insures approximately 60 million Americans, and reimbursement rates for managing health conditions have been reduced over the years as the cost of technology required to run a modern hospital has skyrocketed. At the same time, Medicare reimbursement rates are higher for invasive procedures, such as surgeries, which necessitate longer hospital stays and occupy more bed space. If the majority of surgeries are scheduled for early in the week and none for late in the week or over the weekend, there will be a large variation in patients occupying hospital beds from day to day, which directly contributes to the overcrowding and under-capacity dynamic. The real cause of boarding is the inefficient use of beds, including the restriction of beds to specific specialties and the tendency to schedule surgeries at the start of the week.
When a hospital fails to meet accepted standards of care and a patient is injured as a result, there may be grounds for a legitimate medical malpractice claim. To recover damages, an injured patient or the family of a deceased person has the legal right to file a medical malpractice claim. Consult with a medical malpractice attorney to determine whether the hospital was negligent. If the attorney believes that negligence can be proven, he or she will obtain medical records and other evidence, as well as interview medical experts who may be retained as expert witnesses. After gathering evidence, the medical malpractice attorney will draft and file a complaint.
Inpatient boarding in the ED has long been recognized as a major cause of overcrowding. Transferring admitted patients from the ED to the inpatient hallways is safe and effective. Patients prefer inpatient hallway boarding to remain in ED corridors. This strategy has been adopted by many institutions across the country.
The ED should never be allowed to reach 250% capacity. Delays in transferring admitted patients from the ED result in long waits for patients arriving at external and internal triage who require emergency care. Because of long ED wait times, the US Department of Health and Human Services (DHHS) has issued citations to hospitals under the Emergency Medical Treatment and Active Labor Act (EMTALA). The American College of Emergency Physicians (ACEP), the American Academy of Emergency Medicine (AAEM), and others have published 13 interventions to reduce crowding. The majority of these measures necessitate significant cooperation and resources from the hospital administration. Additional flexible treatment areas with adequate nurse staffing, improved triage resources, additional hospitalists to admit patients, faster laboratory and radiology turnaround times, technicians to transport patients, and staffing to provide bedside registration are just a few examples. Another option is to refer to a hospital as an “internal disaster.” Because a full internal disaster is likely to be unpalatable to most administrators, a policy and procedure for use in limited or focused disasters applicable to the ED can be developed. This would entail bringing in additional hospital nursing and physician staff, ancillary support, and making more room for emergency patients.
Patients should not be evaluated and treated routinely in ED hallways where care is subpar. In the hallway, accurate monitoring is difficult to achieve. Nursing care can be patchy and inconsistent. Care coordination is becoming increasingly difficult in an ED corridor. Intravenous lines are empty. Medication deliveries are delayed. Patients may suffer if worsening patient conditions are not recognized. To protect patients, some states require a 4:1 patient-to-nurse ratio in the emergency department. The administration is aware that these rules may be broken during times of ED overcrowding. Hospitals must devise strategies to avoid providing ED hallway care.
Overcrowding in the emergency department causes physician fatigue and errors. Physicians’ attention is divided among so many patients that they are not always able to focus effectively on the details of each patient’s case. In complex patients, missing details and subtle clues can mean the difference between a correct and incorrect diagnosis. Many EDs task the already overburdened EP with screening large numbers of EKGs for STEMI to meet external standards for early intervention in acute myocardial infarction. In this instance, the screening physician may not be the final treating physician. According to studies, caring for multiple complex and critically ill patients at the same time increases medical errors.
Finally, EPs should be aware of the limitations and risks associated with providing care for patients in ED hallways. Long wait times, constant crowding, delays in transferring admitted patients to inpatient areas, and ED hallway care are all unacceptable to hospital administrators. EPs should be able to report unsafe conditions to hospital administration without fear of retaliation, according to ED leadership. Real solutions require immediate hospital resources.
If you or someone you love suffered injuries because of medical neglect or lack of treatment in an emergency department, call our office today. At DeFrancisco & Falgiatano, we represent injured clients and their families throughout Upstate New York, including Syracuse, Rochester, Albany, Buffalo, Elmira, Binghamton, Auburn, Ithaca, Oswego, Norwich, Herkimer, Delhi, Cooperstown, Cortland, Lowville, Oneida, Watertown, Utica, Canandaigua, Wampsville, Lyons, and surrounding areas. Please call us at 833-200-2000 or contact us via our online form to discuss your case.