As reported by the New Haven Register, April 16, 2006.
Patients Wait for Hours in Hallways; Strain Felt Throughout State
By Abram Katz
Martin Torresquintero was lying on a gurney in an emergency room feeling the pain in his belly grow stronger and stronger as afternoon lapsed into evening.
Doctors and nurses at Yale-New Haven Hospital worked around him, with other patients lining the walls.
His infected appendix was shooting pain through his abdomen.
"My big concern was that it was going to burst. I have a high tolerance for pain. When I say, ‘I'm in pain,' I'm really in pain," said Torresquintero, 41, of New Haven.
He waited two hours for a CT scan amid the frenetic activity of the emergency room - and he had company. "They had so many people waiting everywhere, in chairs and gurneys," he said.
Torresquintero went into surgery after midnight and was discharged the next afternoon. He did not enjoy his emergency department sojourn, but he gave Yale-New Haven high marks for medical care.
"It was superb. They did a really good job," he said.
In fact, Yale-New Haven is one of the few hospitals equipped with the system, software and personnel to handle the growing problem of overcrowded emergency departments, physicians at other hospitals said.
Across the state and the country, emergency departments are filling with patients who have been admitted and are waiting for beds to become available on other floors.
Some wait in halls and corridors for so long that doctors have a nickname for the hapless sick: hallway boarders.
These patients-in-waiting decrease the capacity of emergency departments, strain nurses and other caregivers, and even require doctors to take circuitous routes from one side of the room to the other, emergency physicians said.
"In many cases it's unpleasant and annoying," said Dr. Phillip A. Brewer, an emergency physician at Middlesex Hospital in Middletown.
"Sometimes the crowding can be critically important because it can cause gridlock. People suffer and, I'd say, die, as a result," he said.
"At times when the emergency department is dangerously overcrowded, it's almost impossible to provide timely, efficient care," Brewer said. "It's hard to get from point A to point B. Tempers are short and people are fatigued."
Invariably, the crowding is caused by admissions backing up in the emergency room, doctors said.
There literally is nowhere else to put them.
Many of these patients could be sent to halls upstairs. But they are not, because the state Department of Public Health refuses to sanction the practice, which doctors said is medically acceptable.
The state health department represents the federal Centers for Medicare and Medicaid Services in this instance. The centers have not approved or denied taking patients to another floor, so hospitals do not want to take a chance, doctors said.
Patients would probably receive better care on other floors, they said. But they stay in the busiest and most time-pressed space in the hospital.
"This phenomenon has become commonplace," said Dr. Michael Carius, chairman of the emergency department at Norwalk Hospital.
More people are seeking help in emergency departments, while the number of hospital beds in the United States shrinks and hospitals close, said Carius, past president of the American College of Emergency Physicians.
Statistics from the U.S. Centers for Disease Control and Prevention, the American Medical Association and the American Hospital Association show that, over 15 years, trips to emergency rooms have increased from 90 million a year to 114 million in 2004.
During the same period, about 100,000 hospital beds in the United States were eliminated. The country has 50,000 to 100,000 too few doctors and a nursing shortage approaching 400,000, Carius said.
"This is why we're creating ‘the perfect storm.' There's increasing need, decreasing resources and fewer beds. Emergency departments are caught in the middle and patients are staying there," he said.
Among the many factors that turn the corridors of an emergency room into a de facto medical floor is the acceptable bed usage decided by hospitals, Brewer and Carius said.
Occupied beds produce revenue, meaning that empty beds cost the hospital, Brewer said. Hospitals used to be satisfied with an 87 percent occupancy rate, he said. Now the pressures of managed care have forced hospitals to keep the rate closer to 95 percent, Brewer said.
Some beds may be empty, awaiting patients scheduled for elective procedures, he said.
"Being in the emergency room for 12 to 15 hours so that someone else can check in the next morning - I disagree with that," Brewer said.
Dr. Rob Fuller, chief of emergency services at John Dempsey Hospital in Farmington, said the emergency room becomes over-crowded occasionally.
"It happens to every hospital in the state. Usually you try to put people with less humiliating problems in the hallway," he said, where there is less privacy. "There's no doubt about it, the quality of care suffers," he said.
Why should lingering patients affect care?
"It's like going to a restaurant when it's really busy. You might order french fries and get mashed potatoes. But this isn't about french fries and mashed potatoes. There's no research on this that I'm aware of, but I have the feeling that, the more patients you have, the less attention you can give to each patient," Fuller said.
"Each hospital struggles with its own reasons for overcrowding. They are not insignificant," he said.
Under- or uninsured people may use the emergency room for primary care, but that usually does not cause a problem, Fuller said. "The issue is the sick, complicated patient who requires admission. To take eight to 10 hours from the door to the operating room is not uncommon," he said.
Carius said one of the best ways that hospitals cope is by establishing a "bed czar" to keep patients flowing smoothly.
That's what Dr. Victor Morris does at Yale-New Haven Hospital. He is director of bed resources at the hospital, but he's comfortable with the bed czar title.
"Nationally there is a problem with emergency room crowding. Some hospitals make patients wait for days. You don't want a patient in the emergency room when there is an open bed upstairs," Morris said.
The hospital has computer software that allows Morris and others to see the status of every bed - occupied, empty but dirty, or empty and clean.
The hospital's admitting office assigns beds and informs the admitting doctor and emergency department, which can then monitor the bed. "Doctors can see where the patient will go and the status of the bed," Morris said.
Another computer system at Yale-New Haven ensures that personnel responsible for cleaning beds know where they are needed, he said.
Their display shows beds as brown (dirty), yellow (being cleaned) and gray (clean).
"This prevents ‘bed hiding,'" Morris said. Brewer said nurses have no incentive to add to their already overwhelming work load by cleaning rooms rapidly.
Morris said bed hiding is kept to a minimum and occurrences are usually unintentional.
Yale-New Haven has a fairly liberal placement policy, within reason, he said. Medical patients are placed on surgical floors, but surgical patients never go to medical floors. Adults are not given pediatric beds, and the use of maternity beds is restricted.
Every floor of the hospital also has empty spaces for "overflow beds," Morris said. The third bed in a three-bed room may be left open so that a patient can be placed there if necessary, for example.
"We've been working on improving bed management for five years. Overcrowding in the emergency department can lead to unsafe care," Morris said,
Bridgeport, Waterbury and Hartford hospitals also use computerized bed-management systems.
Meanwhile, physicians have been pressing for legislation to reduce emergency room crowding.
State Rep. Peggy Sayers, D-Windsor Locks, introduced a bill in the February session that would require hospitals to find beds for patients within eight hours of admission. The bill also required hospitals to monitor and track the length of patient stays in emergency departments, and had other provisions for planning and inspections.
The bill was tabled by the Public Health Committee.
Dr. Steven Hanks, chief medical officer of New Britain Hospital, testified against the bill on behalf of the Connecticut Hospital Association.
The CHA contended that the eight-hour limit was arbitrary. Moreover, Hanks said, "The emergency departments in Connecticut are not the causes of overcrowding, though they are the areas most vulnerable to gridlock, in large part because they are the safety net that turns no patient away."
Hanks cited the increasing number of uninsured and under-insured patients who use emergency departments for primary care, a shortage of beds, inadequate supply of nurses and insufficient mental health beds, among other factors contributing to emergency room crowding.
The problem has not escaped the attention of the Joint Commission on Accreditation of Healthcare Organizations, which accredits hospitals in the United States. The commission instituted a requirement last year for hospitals to "develop and implement plans to mitigate impediments to efficient patient flow throughout the hospital."
Emergency room physicians in Connecticut said they wonder when JCAHO will start to enforce the new standard, and whether it will help.
"I'm glad JCAHO is concerned with the problem," Fuller said.
Ultimately, hospitals must be given an incentive to add beds, nursing schools must reopen, malpractice insurance premiums must drop, more people must have access to health insurance, and population growth must stop to begin to solve the problem, Carius said.
"It's a true conundrum. We have to do more for more people, with less resources," he said. "It's an impending disaster."