This is a great Op-ed from a radiologist who understands the health economics effecting patient care that was published in the Wall Street Journal.
Just after World War II, there were 1.4 million hospital beds available in the U.S. The most recent estimates show fewer than 900,000 beds, even though the nation’s population has grown by 120% over the same period. Better care delivery, technology, and changing financial incentives have driven much of this decrease, with hospitals continuing to downsize their staff and operations, making for less-flexible bed management. Also shrinking in number are emergency rooms (ERs), even while demand increases.
The ER has become the de facto multi-specialty clinic of the 21st century. The modern ER no longer just serves as the place for sewing up wounds or triaging patients for more acute care. Delivery of screening, diagnostic, and therapeutic services occur in and around the ER, resulting in huge improvements in stroke, cardiac and trauma outcomes.
In addition to the expansion of services, the ER has also become the medical provider of last resort in most communities: serving insured patients when their private physicians are unavailable and underinsured or uninsured patients. This usage has led to a significant increase in demand for ER space. Most ERs report crowding at some point during the day, and, increasingly, wait times and lengths of stay are the preferred metrics in evaluating ER quality of care.
Boarding results in poorer outcomes (including higher mortality) for patients. Beyond the mere discomfort of lying on a stretcher for a longer period of time, inpatient nurses and doctors do not see them even though they have been determined by a physician to need hospital care. Patients that are boarded have longer overall lengths of stay compared with comparable admitted inpatients and, unsurprisingly, report lower overall satisfaction.
Health care and health is also impacted. Studies show that mortality increases along with the duration of ER boarding and that boarding increases the amount of time in the hospital for all patients. Stroke patients, in particular, have poorer management and outcomes when ERs are crowded. Despite the harm, 90% of ERs report frequent overcrowding and most have experience with boarding.
In other industries, such an experience would lead to rapid operational redesign and surge management to minimize harm. Airlines have figured out how to move hundreds of thousands of travelers after major storms; and utilities, too, know how to manage disasters due to weather events. In each of these cases, there is a short-term impairment of services that is quickly resolved. And yet in health care, boarding appears to be as bad as ever, becoming part of the day-to-day functioning of our ERs and the patients that need their services as just another inconvenience of being sick, rather than a problem to be solved.
There are simple fixes to this problem: Hospitals can free up inpatient bed space by opening new units or staffing shuttered ones, or they can reduce (or even modify timing to less predictably busy times) lucrative elective admissions until they achieve a more manageable equilibrium. However, both of these strategies have enormous financial consequences for hospitals, which already operate on low single-digit margins. The more challenging solutions revolve around improving streamlined care delivery in the ER and designing better bed management strategies at the inpatient hospital level. Meanwhile, data show that inpatient boarding, where admitted patients wait for beds in inpatient hallways instead of the ER, is a safer alternative that has better patient satisfaction.