Researcher: ‘The Levees Have Broken’ at emergency departments

By Christopher Cheney

Hospital emergency departments have been under severe strain during the coronavirus pandemic, according to a pair of new research articles.

The new studies examine boarding of patients in emergency departments before they are moved to inpatient beds and patients who left without being seen (LWBS), the latter presumably because of ED crowding and long wait times. The Joint Commission has deemed extended boarding of patients in the ED as a patient safety risk, with boarding recommended not to exceed four hours. Relatively high LWBS rates can have significant negative consequences for patients if they are deferring care for acute conditions.

Both studies were published by JAMA Network Open.

The ED boarding study is based on hospital measures data collected through a voluntary peer benchmarking service offered by Epic Systems Corporation—the leading electronic medical record company in the country. Measures were collected on a monthly basis from January 2020 to December 2021. The study features three key data points:

  • Hospital inpatient bed occupancy rates had a threshold association with boarding time. When occupancy rates were higher than 85%, ED boarding was higher than The Join Commissions four-hour standard for 88.9% off hospital-months.
  • For hospital-months with occupancy rates higher than 85%, the median ED boarding time was 6.58 hours versus 2.42 hours during other hospital-months.
  • For all hospitals, the median ED boarding time was 2.00 hours in January 2020, 1.58 hours in April 2020, and 3.42 hours in December 2021.

The ED boarding study’s findings indicate strains on EDs before the pandemic likely worsened during the pandemic, the study’s co-authors wrote. “We found that hospital occupancy greater than 85% was associated with increased ED boarding beyond the 4-hour standard. Throughout 2020 and 2021, ED boarding increased even when hospital occupancy did not increase above January 2020 levels. The harms associated with ED boarding and crowding, long-standing before the pandemic, may have been further entrenched.”

Left without being seen study

The LWBS study is also based on hospital measures data collected through a voluntary peer benchmarking service offered by Epic Systems Corporation. The measures were collected on a monthly basis from 2017 to 2021.

The LWBS study includes two key findings:

  • Median rates for hospital LWBS increased significantly from 1.1% in 2017 to 2.1% at the end of 2021.
  • Among the worst performing hospitals, the LWBS rates for ED patients increased from 4.3% in the beginning of 2017, to 4.4% in January 2020, to 10.0% at the end of 2021.

LWBS at EDs is troubling, the study’s co-authors wrote. “Access to emergency care cannot be considered universal until all patients presenting to EDs receive high-quality treatment for time-sensitive conditions. Given contributing system constraints, LWBS should be viewed as a failure to offer equitable access to acute care.”

Lead author’s perspectives

The lead author of both studies, Alexander Janke, MD, MHS, says the research indicates the pandemic has compromised a crucial part of the U.S. healthcare system. “Emergency departments are the levees on acute care demands in the U.S. While once there were decompression periods in even the busiest EDs, what we are seeing here, as others are seeing in Canada and the U.K., demonstrates that the levees have broken,” he said in a prepared statement.

The studies show long-standing problems at EDs have worsened during the pandemic, Janke said. “Boarding and overcrowding in EDs have been a growing issue for over 30 years. Incredible work has been done in the emergency medicine community to make our care better, more accurate, and nimbler using limited resources. But without more space and staff in the hospital, and downstream in skilled nursing facilities and across community settings, this crisis will continue.”

Christopher Cheney is the senior clinical care​ editor at HealthLeaders. This story first appeared HealthLeaders Media