A few months back, a pregnant friend of mine developed pain in her gut so intense she couldn’t get out of bed, and, on the advice of her doctor, ended up at one of the Main Line emergency rooms.
Her experience there was … not good. Of course, the ER is nobody’s trip to the Four Seasons (even on the Main Line), but the Cliff’s Notes version of her saga involves a misdiagnosis from a physician’s assistant; a long, solitary wait in the exam room, expecting a doctor who never came; two rounds of futile treatment; zero relief from her agony.
Despite ongoing, debilitating pain, she was sent home, where she spent two more sleepless, terrible days. She called the hospital back to tell them she wasn’t fixed. They told her the next step was a trip to a colorectal specialist. The earliest appointment available? A month away. But in a stroke of amazing good fortune, her mother had a connection. My friend got an emergency appointment, which is how she learned that what the first ER told her was internal hemorrhoids was actually an impaction and abscess (a potentially deadly condition); she’d need immediate surgery.
Thus she found herself in her second suburban ER of the week, waiting for her surgery. This time, she sat for hours in a “packed and disgusting” waiting room, amid what she called “a shit show,” as well as what she assumed were possible Covid patients. Finally, several hours in (and three and a half days after her first ER trip), she was wheeled into a successful surgery.
She’s fine today, though embroiled in an ongoing battle with the first hospital over paying the bill—this after one of the hospital’s ER doctors even agreed that she didn’t get the level of care she should have, she says. He was apologetic; they were all so overloaded and overwhelmed with Covid, he told her.
What our ERs have shown us over the last several months is what an emergency we’re facing—and that it’s going to take more than just controlling our Covid numbers to really fix it.
While she was telling me all this, two other stories popped into my head. The first involved a similarly hellish experience from an acquaintance who had recently sliced off part of his finger, landing him in a Philly ER, where—long story short—he found himself waiting in a treatment room, putting pressure on his own wound at the direction of a doctor who’d told him someone would come bind it. Nobody came. The pain was so intense he almost passed out. It seemed to him he was forgotten by the medical staff, save one nurse who, unperturbed by the sight of him leaning against the wall in agony, asked him for his credit card for payment, and then for his signature. (He obliged, with his good hand.)
Don’t get him wrong: “It’s not like I can’t hear what other people are in with,” he says. “Someone was hit by a car. Someone was overdosing. The ER is like M.A.S.H., right? I understand where on the triage hierarchy I sat. But this was really just very weird.”
The other story bouncing around in my head wasn’t another anecdote, but a reported piece I’d recently seen in The Atlantic, by Ed Yong. “Hospitals Are in Serious Trouble,” the headline declared. The story started like this:
When a health-care system crumbles, this is what it looks like. Much of what’s wrong happens invisibly. At first, there’s just a lot of waiting. Emergency rooms get so full that “you’ll wait hours and hours, and you may not be able to get surgery when you need it,” Megan Ranney, an emergency physician in Rhode Island, told me. When patients are seen, they might not get the tests they need, because technicians or necessary chemicals are in short supply. Then delay becomes absence. The little acts of compassion that make hospital stays tolerable disappear. Next go the acts of necessity that make stays survivable. Nurses might be so swamped that they can’t check whether a patient has their pain medications or if a ventilator is working correctly. People who would’ve been fine will get sicker. Eventually, people who would have lived will die.
In fact, that haunting piece was but one of many (many, many!) stories popping up lately looking at what Covid, mostly Omicron, was doing to America’s hospitals (overwhelming them, including ones here in Philly). And not just our hospitals, but our ERs (it’s “the worst it’s ever been,” one ER doc at Johns Hopkins told NPR earlier this month), and not just our ERs, but the overburdened and burned-out practitioners.
That’s all scary enough, contemplating such big holes in the safety net of the American healthcare system, but here’s the rub: The crowded, chaotic emergency rooms and long wait times aren’t just a Covid problem.
“It’s been getting worse” for years, offers one friend of mine, a Philly-area ER doctor. And yes, of course, he says, the pandemic—with its extra patients, supply chain issues, staffing absences, nursing turnover and the loss of expertise that’s involved there—has affected everything for the worse.
But also: “We’ve been operating on the edge for a long time.”
Worse care, longer stays, higher costs…and more death
As far back as the early 2000s, researchers were looking at the problem of ER overcrowding, which isn’t, as you might guess, just an issue of patient inconvenience and lengthy, uncomfortable wait times, or even professional burnout, which has long since been an issue in this discipline: Studies have also consistently linked long emergency room waits and crowding with worse care, longer hospital stays, higher costs and, yes, greater risk of death.
In 2008, a one-day survey of seven cities (Chicago, New York, L.A., Houston, Washington, D.C., Denver and Minneapolis) showed these cities’ ERs at 15 percent over capacity on average, with none being able to handle a new surge of patients. Meantime, ER visits rose more than 60 percent from 1997 until just before the pandemic; and traffic through the country’s emergency rooms, one doctor noted a couple years back (pre-Covid) in the New York Times, has been “growing at twice the rate projected by United States population growth and has been for almost 20 straight years.”
There are loads of circumstances and trends that can help explain some of that, and many of them have gotten quite a bit of attention over the last decade or so—namely, the weaknesses in our health system, from lack of health care coverage to widespread lack of access to primary care, that lead people to neglect or put off their health care until it’s at an emergency level … or to see the E.R., which is obligated to treat everyone whether they can pay or not, as the only place they have to go to be treated for whatever ails them.
There are other root, systemic and societal issues that have led to more of us going to the ERs—like say, our gun crisis (here, and in other cities), for example, the opioid crisis, and the number of people struggling in one way or another with one the many social determinants of health (education, poverty levels, employment, housing …) that are linked to more frequent ER visits.
And still another driver of high ER demand, noted the doctor in the aforementioned Times story is the insufficient care coordination, follow-up post-hospital visit, and regular access to basic healthcare maintenance on the “outside”, which leads to repeat customers. So to speak.
Many of these are painfully real problems felt across our city, problems that health professionals and community leaders in Philadelphia are working to address in myriad ways. But one thing all of those issues have in common? They’re all about the demand side of the equation. Much focus, understandably, is on the people who are flooding into the ERs, overwhelming them.
What about the ERs themselves?
A supply-side problem
It’s this—the ER system and its resources, a.k.a. the supply side of the equation—that Penn emergency physician and economist Ari Friedman (who wrote his PhD dissertation on, yes, ER crowding) wrote about with Penn economist and professor of health-care management Mark Pauly for the Inky way back in 2020. Mere weeks before Covid hit, the pair made the case that “the core problem is the supply of resources the system makes available to treat that demand, and the nature of ER care.”
They argued that we needed to invest more in meeting the demand by upping the supply, literally “to pay the cost of more hospital capacity.” Capacity means more beds, more equipment, and more professionals, from technicians to docs to facilities maintenance—all the resources it takes to care for people. (As for the pre-Covid timing, Friedman says wryly, “2020 was a great time to write that because it would have been nice to have the capacity in advance, right?”)
At the time, the pair proposed a couple ways to bolster capacity in the ER, which would help ease the burdens of consistent ER overcrowding. The first, and maybe most obvious, was to fund the ERs themselves so they could have more capacity for patients. Essentially, ERs—which tend to “lose” money in a hospital system, given that they cover everyone whether they get reimbursed by insurance or not—are designed to run incredibly lean and mean, essentially to “avoid having periods of expensive downtime and underused resources,” as the duo put it.
So, yes, an ER better equipped to deal with higher-than-average demand (or even just the new average demand) might mean occasional “waste” as resources go unused. But it could also relieve some of the backup. And yet, as the authors point out, you can see how paying for “waste” or more slow times in order to be better prepared for peak times is a hard (impossible?) sell for the hospitals or the insurers on whose backs this would fall, even if it eases some ER pain. (Case in point: Some for-profit hospitals even forced pay cuts on doctors during slow ER moments of the pandemic, Friedman notes, because the hospitals operated on a “volume-based reimbursement system.” The idea of “extra” anything in case of surges or higher than average volume feels … unlikely.)
All of this has some historical context, Friedman tells me. In the ’90s, he says, too many empty hospital beds were driving up the cost of healthcare; efforts to shave those costs ushered in a new emphasis on outpatient settings. That’s actually another thing that’s driven “the rise of the emergency department,” he says. “If you’re gonna have a lot of outpatient stuff, you got to have a place for people to go when something goes wrong, right?”
In that effort to cut losses, hospitals aimed for fewer empty beds, which has meant fewer open beds in general, “basically post-Clinton,” Friedman says. According to data compiled from the American Hospital Association, there were roughly 1.5 million hospital beds in the country in 1979; in 2019, there were 919,000.
Here in Philly and the surrounding area, we’ve seen the trend recently, with hospital closings and even growing systems cutting beds. In 2018, Jefferson announced it was cutting 400 beds by 2022. This move, Jefferson’s VP of media relations said at the time, was thanks to advances in medical technology that reduced the need for overnight stays. He was referencing medical advances, but another advance of note is telemedicine, where Jefferson has been at the forefront. (To see an emergency doctor on telemedicine requires a $59 fee up front, paid via credit card.)
But back to the big picture here. The upshot of the 1990s-era shift, Friedman says, is that we’ve tended to run hospitals at a higher capacity for decades now. “And if you’re 90 percent full, on average,” Friedman says, “it doesn’t take that many COVID patients and mess things up pretty badly.”
There was a second suggestion that Friedman and Pauly offered up in 2020 to address ER overcrowding: Looking at the whole hospital, and “the lack of inpatient beds to take patients out of the ED and to their ultimate destination.” And this is the issue that Friedman thinks is the best one to focus on today—right now—to ease ER overcrowding.
After all, a lack of inpatient beds (or the inefficient flow of ER patients to those beds) keeps patients in the ER much longer than they should be, after they’ve received their emergency care and are ready to be moved elsewhere. It gums up the whole works, even for patients who would otherwise be in and out.
This wildly common practice is called “boarding patients,” and it’s long been a big part of ER overcrowding. According to one NPR report, the Institute of Medicine called boarding a “national crisis” way back in 2006; by 2016, two-thirds of hospitals said they regularly boarded patients for more than two hours—a number up from 57 percent in 2009. Again, it’s not just about the logistical inconvenience: a study in the early 2000s showed that critical patients who board for more than six hours in the emergency room are 4 percent more likely to die.
Friedman believes boarding is one of the particularly pressing issues in hospitals across the country right now. (“Anecdotally, there seems to be a lot out there.”) He’s not alone in this: Last fall, Sharon Anoush Chekijian, assistant professor for emergency medicine at Yale, wrote about boarding in a piece for U.S. News and World Report.
“Most days in the ED where I work begin with 120 patients—most of them “boarding” or waiting for a bed upstairs in the hospital,” she wrote. “We have only 53 beds in the ED to begin with.” By 11 a.m., she says, her department is “bursting at the seams.”
There is good news
If there’s any good news here—and admittedly, this isn’t exactly a “good news” story—it’s that there are ideas floating around out there for how to tackle boarding as an ingredient in the crowding and chaos in ERs.
One biggie is financially incentivizing hospitals to board less and get patients to beds faster and more efficiently. This is not the case now; quite the contrary. In their op-ed two years ago, Friedman and Pauly wrote that the insurers could “pay less money for any admission where the insured waited more than two hours” between admission and moving to an inpatient bed. In short? Hospitals would lose money if they boarded patients too long.
“This would force hospitals to redistribute resources from the whole hospital to the ED rather than taking a narrow perspective that the ED ‘loses money.’” The hospital should be rewarded financially, not punished financially, for sending patients who need further care, even if that care is not one of the more “lucrative” conditions, to the right place.
And speaking of getting people to the right place: “In most hospitals in the U.S., the emergency department is the only place that will have patients in a hallway bed,” Friedman says. “Right? We don’t even think about that, but it’s true. But it turns out that there are a lot of hallways in the hospital. And a lot of those hallways at any given moment in time, have associated nursing staff that could probably handle one extra patient on a ward of 30 beds, right, instead of having an emergency nurse handle a waiting room full of 30 patients.”
It’s a change that is as much about “political will,” as Friedman puts it, as it is cost. And sure, it’s a short-term fix … but if that move frees up a bed you’re waiting for in the ER, it matters.
There’s also a legislative tack: Some countries have laws that limit the length of time patients can be in the ER. Britain, for one, has a max time of four hours. And by 2014, an NPR op-ed from a pair of Boston docs pointed out, it was working for 94 percent of patients. (Canada, Australia and New Zealand, too, have had success with similar laws, they added.)
This piece also zeros in on how some hospitals have changed (“smoothed”) the pacing of surgical scheduling to great effect—things like longer wait times for those lucrative elective surgeries and better streamlining patient discharges. (This is actually why we saw elective surgeries put on hold in some hospitals during Covid: It opens up more capacity in the hospital, and can provide relief for an overpacked ER.)
In Cincinnati’s Children’s Hospital, for example, these sorts of efforts at planning and smoothing surgical schedules, pacing surgeries more efficiently, ended up making more revenue rather than less, raised average capacity, and lowered boarding rates … plus saved a massive amount of money that they didn’t end up needing to shell out for an expansion.
There’s also telemedicine, which grew exponentially at both Penn and Jefferson during Covid, and which has shown in some studies to be promising as a tool for reducing length of stays in ERs and also crowding. (Though in our state, regulation and reimbursement barriers still limit the reach of telehealth.)
In her piece, Yale doctor Chekijian also pointed to a host of ways to address boarding issues, on both the demand and the supply side. She’s a proponent of realigning financial incentives against boarding, too, and throwing resources at boosting capacity and turnaround times for outpatient labs and radiology. And the same “triggers” that activate the hospital’s disaster protocols should apply to the indicators of crowding, she says, so that boarding doesn’t become the accepted norm, but instead, is seen as a problem worth addressing urgently as an issue of patient safety.
You can see, maybe, how any one of these approaches could be its own story, more complicated and layered and interconnected than I’m getting into here—just as ER crowding (before Covid, during Covid, after Covid) is a complicated, layered problem. The point here though, is that it’s beyond time to connect the dots, to see what Chekijian called the beginning of a “crashing descent into collapse.”
“I often feel like the proverbial canary in the coal mine,” she wrote, “acutely aware of how broken medicine in the U.S. is and wondering if anyone else has noticed.”
This is not unlike what my friend, the ER doctor, has said to me, more than once. It’s not unlike what patients are feeling in the waiting rooms, or what doctors are pleading us to see lately, in stories across the country.
So have we noticed yet? What our ERs have shown us over the last several months is what an emergency we’re facing—and that it’s going to take more than just controlling our Covid numbers to really fix it.
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