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.
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ACEP Now: Vol 42 – No 08 – August 2023References
- 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.
- Bernstein SL, et al. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med. 2009;16(1):1-10.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- American Nurses Association. Nurses in the workforce. ANA website. https://www.nursingworld.org/practice-policy/workforce . Accessed July 13, 2023.
- 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.
- 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.
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One Response to “ED Boarding”
August 22, 2023
Christian TomaszewskiGreat suggestions in your five recommendations.
Unfortunately, in California #2 and #3 (offsetting nursing tasks) do not really work. The bottleneck is the nursing ratio (4:1, except ICU cases 2:1). You can hire all the LVNs and techs you want; we cannot violate that ratio. And for some reason, waiting room patients do not count in the ratio, and so get “ignored.” We need waivers for ratios, on both the inpatient and ED sides to cope with the volume, provided we do give nurses help with such “care extenders.”
As for #5, yes, ED physicians need to engage with population health. But decreasing overall ED volume is not necessarily the answer. The worried well to some extent subsidize ED operations. We could certainly accommodate many more Level 3/4 triage patients (treat and discharge) if we were not holding so many admissions in the ED, which lengthens every ED patient’s workup and stay.