If you’ve ever been to the emergency room, chances are it was overcrowded and you had to wait a while.
But that long wait isn’t necessarily due to patients coming to the ER for non-critical medical care, according to a new report from a committee of doctors convened by Connecticut lawmakers.
Rather, emergency room “boarding” is to blame.
“Boarding” is when patients are made to stay in the ER, often on a bed in a hallway, as they await transfer to another part of the hospital.
These delays can last hours, days, weeks, or longer, according to the American College of Emergency Physicians.
“People often think [ERs are crowded] because people are over utilizing the ED,” said Dr. Chris Moore, an ER physician at Yale New Haven Hospital, and committee member who helped author the report.
“But one of the major issues is that hospital patients who are admitted remain in the emergency department,” he said. “That constricts the space to take care of and evaluate incoming patients, and those are what's called boarded patients.”
Moore and the committee of doctors outlined the state’s boarding crisis in a final report handed over to lawmakers in advance of the legislative session that began on Jan. 8.
Across Connecticut, ERs provide care to more than 1.3 million residents, regardless of their ability to pay. In addition to life-saving treatment for heart attack, stroke or trauma, ERs are the last safety net for many working poor, along with people in crisis from mental health or substance use disorders.
Doctors say overcrowding in the ER is a public health crisis that can result in delays in care, missed diagnosis, harm to patients and even death.
Non-critical patients presenting at the ER not the issue, report says
The group advised lawmakers that ER crowding is not the result of ER overutilization, even when patients presented at Connecticut ERs for non-emergency symptoms. The top 10 reasons people go to ERs statewide for non-threatening conditions according to state data are:
- Urinary tract infection
- Other chest pain
- Low back pain
- Dizziness and giddiness
- Acute upper respiratory infection
- Unspecified fever
- Nausea with vomiting
- Suspected exposure to unspecified communicable disease
- Unspecified abdominal pain
- Acute pharyngitis (sore throat)
The working committee wrote that while it supported the use of urgent care centers and primary physician practices as a means to reduce ER crowding, “it is essential that patients are not prevented from seeking care in the ED when they believe they need it.”
According to the Prudent Layperson Standard, a federal law that provides patient protection, anyone can receive emergency care regardless of insurance status or ability to pay.
The Connecticut group of doctors wrote that patients are not expected to know if their symptom is serious, and non life-threatening conditions are the easiest to deal with in the ER.
“Uncomplicated upper respiratory infections (URIs), sprained ankles, and sore throats may be able to be cared for elsewhere, but they are not what is causing ED crowding as they can be quickly discharged,” the report stated.
Moore acknowledged that many patients in hospitals in Connecticut do not require hospital-level care, but are unable to be placed “for various social issues, or there's just not space for them, whether they're elderly or have mental health or substance abuse issues.”
Proposed solutions
The committee is mandated to advise legislators and the commissioner of the Department of Public Health about ways to alleviate ER crowding and the lack of available ER beds in the state.
Proposed solutions outlined to lawmakers include:
- Establishing a quality measure on hospital boarding in every ER statewide. This database would be implemented by the Office of Health Strategy and data would be publically available.
- Increasing Medicaid reimbursements, which would allow hospitals to potentially fund solutions to reduce ER wait times.
- Establish and fund a Connecticut “ER ombudsman” to monitor the flow of patients through hospital ERs.
- Implement a statewide information system for ER capacity, hospital capacity, and transfers.
“It is very important for the legislature to address the Medicaid rates here in Connecticut,” Dr. Gregory Shangold, committee member and ER physician at Northeast Emergency Medicine Specialists.
“They have been flat for 17 years,” he said. “Additionally, the impediment of prior authorization severely hampers the flow of patients through the hospital and contributes greatly to the boarding situation.”
Prior authorization can be required by insurers for high-cost hospital stays, and leave patients lingering as doctors and insurers hash out what’s medically necessary and who will pay for the care.
The Connecticut Hospital Association [CHA] says it is also in favor of increasing Medicaid reimbursements and addressing insurance prior authorization delays, two solutions it believes would more quickly alleviate the ER boarding crisis.
“We should dedicate limited resources to solutions that address the known issues that influence wait time, [rather] than more and more data collection,” CHA said.
Hospitals in Connecticut are required to analyze the percentage of patients who are admitted to the hospital after presenting at the ER, but were transferred to an available bed outside the ER more than four hours after an admitting order. Starting this year, the data must be submitted annually by hospitals by March 1.
