In November 2022, the American College of Emergency Physicians sent a letter to President Biden on behalf of 34 organizations, asking to convene stakeholders to identify solutions to address the emergency department (ED) boarding crisis.1 The letter detailed ED physician stories, highlighting the preventable harms from boarding, crowding, long waits, staff shortages, burnout, and the disproportionate impact on behavioral health and pediatric populations. Hospital crowding and ED boarding have been longstanding and persistent crises for more than two decades, yet have progressively worsened over the COVID-19 pandemic.2

Early pandemic days brought uncertainty, personal risks to clinicians, and waves of COVID-19 patients. Over time, this caused attrition among ED physicians. Even more so, nurses left practice or migrated to non-hospital settings. There is no easy fix to the nurse-supply problem. A pre-pandemic analysis estimated a shortage of 500,000 registered nurses by 2030.³ Given the current attrition rate, this is most likely an underestimate. Today, many hospital inpatient units, EDs, and post-acute care locations cannot adequately staff due to nursing shortages. 

Emerging data on ED crowding are stark. Left without treatment (LWOT) rates increased from a median of 1.1 percent pre-pandemic (interquartile range [IQR], 0.5-2.5 percent) to 2.1 percent post-pandemic (IQR 0.6-4.6 percent).4 LWOT rates were as high as 10 percent in the 95th percentile. Internal data from US Acute Care Solutions EDs show similar trends, with progressively lengthening ED length of stay (LOS) and increasing LWOTs. Here’s what the government can do to impact the hospital crowding and ED boarding crisis.

Solution 1: Immediately reintegrate the admitted ED LOS measure into public reporting and Medicare stars for hospitals

Historically, hospitals measured and reported ED LOS for admitted patients, a proxy for the ED boarding time. The Centers for Medicare and Medicaid Services (CMS) developed and maintained the measure. It was submitted in 2008 to the National Quality Forum (NQF), which convenes external groups to endorse measures. NQF re-endorsed the measure in 2014. In November 2018, CMS withdrew the measure. NQF endorsement was removed. CMS used the following justification: “Costs associated with the measure outweigh benefit of its continued use in the program.”⁵ CMS also “… respectfully disagree[s] that the removal will result in hospitals not working to maintain low boarding time.”⁶

It’s time to bring the measure back. It should be publicly reported so patients can assess how long they might have to stay in the ED boarding prior to transfer to their inpatient bed. It should be included in Medicare star ratings for hospitals, which is a summary measure of hospital quality for consumers. The admission LOS measure formerly reported only the median time. Future versions should also report the 75th and 90th percentile times for full transparency. It should also differentiate boarding times for psychiatric patients, who are at high risk for very prolonged boarding. Public data on boarding times, ideally tied to hospital reimbursement, will help change the perverse financial incentive that hospitals make more money when they preferentially give beds to patients with lucrative scheduled procedures over ED patients.7

Solution 2: Unload the nursing workforce of less complex tasks by allowing related professionals to increase their scope of practice

To reduce crowding, the central issue hospitals need to address is a shortage of nursing labor. Allowing some lower-level tasks performed by nurses to be completed by related professionals would rapidly address the issue. An immediate step would be the federal government working from the top down with local regulatory bodies to adopt new scopes of practice for workers and delegate some, less complex, currently nurse-only, tasks to others. For example, EMS personnel, certified nursing assistants, and medical assistants could reduce the nursing work burden for tasks such as drawing blood, hanging simple fluids, placing IVs, and other tasks. This would involve partnering with groups like the American Nurses Association or the Emergency Nurses Association to develop programs for nurse extenders. ED physicians lead teams of advanced practice clinicians in some hospitals. Similarly, nurses could lead their own teams with these new roles. Some hospitals have already embraced the concept of nursing extenders.8 Additionally, military branches have skilled workers with complementary skills where an existing workforce could be immediately deployed to meet these needs. Navy corpsmen deliver a wide range of nursing-related tasks in U.S. military facilities. Another idea would be to expand the National Health Services Corps to include graduating high school seniors who could serve in these novel roles for two years, gaining skills and loan forgiveness for college or trade school.

Solution 3: Fund EDs and hospitals to address hospital crowding and ED boarding

With direct funding from the federal government, there would be additional resources to address local issues, customized to hospital needs. Such uses of funds could include hiring ancillary staff to offset nursing tasks, which would address the staff shortages that have caused many hospitals to close available, but now empty, beds. These bed closures directly worsen boarding because there are fewer spaces to send ED patients after hospital admission. Those beds need to reopen. Funding could also be directed further downstream to post-acute facilities where decreases in bed availability have caused upstream congestion in hospitals, also leading to ED boarding.

Alternatively, funding could be deployed to provide resources to internal hospital teams to address remediable flow issues. Funds could be used to hire additional physicians or advanced practice clinicians to augment clinical gaps, or to provide leadership. Such funding would create an imperative for hospitals to focus on ED boarding with additional dedicated human resources at a time when hospital budgets are strained. 

Solution 4: Further increase funding to bolster the nursing pipeline

U.S. nursing schools turned away 80,407 qualified applicants in 2019 due to a lack of faculty, education space, and resources.9 Simultaneously, the median age of registered nurse faculty is 52 years, suggesting a wave of near-term retirements that will further diminish capacity to train new nurses.10 Increased funding is necessary to ensure each class includes the maximal number of qualified applicants. 

On October 3, 2022, the Department of Labor announced $80 million in funding to expand the nursing pipeline through the Nursing Expansion Grant Program. This included multiple pathways: the nurse education professional track to increase the number of clinical and vocational nursing instructors; the nursing career pathway track to train frontline health care professionals; and special grants to support accelerated learning and expanded access to clinical residencies and specialty care rotations.11 While these are steps in the right direction, the U.S. Bureau of Labor Statistics projects that more than 275,000 additional nurses are needed from 2020 to 2030.¹² That $80 million is less than $300 per needed nurse. More funding is needed.

Solution 5: Fund emergency physicians to manage population health, thereby reducing ED volume through innovative care delivery and payment models

If there’s one thing we’ve learned from the pandemic, novel technologies can improve our ability to manage patients remotely. Telemedicine is already being used to change how low-acuity patients are cared for, with off-site physicians diverting patients to the right setting. But these programs are primarily local. It’s time to create payment models to expand them. Expanding these models would allow ED physicians to embrace our role as “available-ists.” It would also enhance our ability to impact population health and reduce total cost of care. Additionally, pre-ED telehealth, post-ED telehealth, and other programs that address frequent use are effective ways for ED physicians to improve patient safety, increase efficiency, and unload hospitals of patient care that may be better delivered in other settings.

One innovative way to do this would be by changing the way that ED physicians get paid, moving to capitated payment models or global budgets that EDs could opt into. Traditional fee-for-service makes telehealth and frequent-user programs more challenging to fund. Global budget pilots would need to keep ED physicians whole and provide additional resources for real population health activity led by ED physicians. Global budgets may be the long-term solution to bridge the funding gap for emergency medicine’s participation in population health.

Ultimately, there are many ways to address ED crowding and boarding. What’s clear from the emerging data: our experience as clinicians as well as our patients’ is that the system is unraveling. ED crowding and boarding are causing patient experiences and outcomes to worsen. The question is not whether the government should act, but how.  The time is now to address this longstanding, progressively worsening, public-health crisis. 

References

1. American College of Emergency Physicians, et al. Letter to President Biden. ACEP website. https://www.acep.org/globalassets/new-pdfs/advocacy/emergency-department-boarding-crisis-sign-on-letter-11.07.22.pdf. Published November 7, 2022. Accessed July 13, 2023.
2. Bernstein SL, et al. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med. 2009;16(1):1-10.
3. Zhang X, et al. United States registered nurse workforce report card and shortage forecast: A revisit. Am J Med Qual. 2018;33(3):229-236.
4. Janke AT, et al. Monthly rates of patients who left before accessing care in us emergency departments, 2017-2021. JAMA Netw Open. 2022;5(9):e2233708.
5. Centers for Medicare & Medicaid Services. Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and policy changes and fiscal year 2022 rates; quality programs and Medicare promoting interoperability program requirements for eligible hospitals and critical access hospitals; changes to Medicaid provider enrollment; and changes to the Medicare shared savings program. CMS website. https://www.federalregister.gov/documents/2021/08/13/2021-16519/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the. Published August 13, 2021. Accessed July 13, 2023.
6. Weiner S, Venkatesh A. Despite CMS reporting policies, emergency department boarding is still a big problem—the right quality measures can help fix it. Health Affairs website. https://www.healthaffairs.org/do/10.1377/forefront.20220325.151088/. Published March 29, 2022. Accessed July 13, 2023.
7. Kelen GD, et al. Emergency department crowding: The canary in the health care system. Catalyst website. https://catalyst.nejm.org/doi/full/10.1056/CAT.21.0217. Published September 28, 2021. Accessed July 13, 2023.
8. Huynh AP, Haddad LM. Nursing Practice Act. Stat Pearls/NCBI website. https://www.ncbi.nlm.nih.gov/books/NBK559012/.  Last updated July 18, 2022. Accessed July 13, 2023. 
9. Hamlin K. Why is there a nursing shortage? Nurse Journal website. Available at: https://nursejournal.org/articles/why-is-there-a-nursing-shortage/. Updated March 21, 2023. Accessed July 13, 2023. 
10. American Nurses Association. Nurses in the workforce. ANA website. https://www.nursingworld.org/practice-policy/workforce . Accessed July 13, 2023.
11. U.S. Department of Health and Human Services. FOA-ETA-22-16, DOL Nursing Expansion Grant Program Department of Labor Employment and Training Administration. Grants.gov website. https://www.grants.gov/web/grants/view-opportunity.html?oppId=341995. Published October 3, 2022. Updated December 15, 2022. Accessed July 13, 2023. 
12. U.S. Department of Labor. News release 22-1946-NAT: US Department of Labor announces $80m funding opportunity to help train, expand, diversify nursing workforce; address shortage of nurses. US DOL website. https://www.dol.gov/newsroom/releases/eta/eta20221003 . Published October 3, 2022. Accessed July 13, 2023.

DR. RAHMAN is a 2022–2023 clinical innovations fellow at US Acute Care Solutions and works clinically at LifeBridge Health in Baltimore. He went to medical school at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, and completed emergency medicine residency at St. John‘s Riverside Hospital in Yonkers, N.Y., where he served as chief resident. 

DR. HEMMERT is the medical director for the Department of Emergency Medicine at the Hospital of the University of Pennsylvania in Philadelphia, and an assistant professor of clinical emergency medicine at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. He is also the founder and associate fellowship director for the emergency medicine administration and leadership fellowship, a groundbreaking collaboration with the Wharton School in Philadelphia.

DR. PINES (@DrJesspines) is the chief of clinical innovation at US Acute Care Solutions and a professor of emergency medicine at Drexel University in Philadelphia. He works clinically as an emergency physician at George Washington University Hospital in Washington and Allegheny General Hospital in Pittsburgh.