Emergency departments (EDs) are currently dealing with big problems of overcrowding and boarding. The number of patients keeps growing, putting more pressure on EDs to find innovative solutions. One approach some EDs try is using hallway beds to handle the overflow. But here’s the thing—it is unknown how this practice impacts patient outcomes and how well the EDs function.

More people are showing up at the ED seeking help for emergencies, social crises, or even routine care. Patients leave without being seen, and those waiting longer often have even worse medical conditions.¹ And it’s not just the patients who suffer—ED staff experience burnout, productivity decreases, errors increase, and costs increase.²

We explored the impact of placing patients in hallways on bread-and-butter ED operations. We looked at things like how long it takes to get a bed, how long it takes to see a clinician, and what happens to the patients downstream. Understanding these factors will help us determine if hallway placement is actually helping or if there are hidden costs.

But let’s not forget the bigger picture. Any care in the hallway is undignified, and ED crowding is a complex issue requiring a comprehensive solution. It’s time for hospital administrators, physicians, policymakers, and everyone involved to come together and find ways to reduce crowding, improve patient flow, and deliver high-quality care.

Our Findings

In a retrospective observational study encompassing two EDs within a larger health system, more than 320,000 patient visits were analyzed. Data were collected on demographics, emergency severity index (ESI), chief complaint, and operational factors. The study’s primary outcomes were door-to-bed time, bed-to-emergency physician, and emergency physician-to-disposition time. The results demonstrated that hallway placement reduced door-to-bed time but significantly increased bed-to-emergency physician time and emergency physician-to-disposition time.

Additional regression analysis found that male patients and patients with Medicaid or self-pay were more likely to be placed in hallways.³ While door-to-bed time decreased, unfortunately, it led to a considerable increase in bed-to-emergency physician and emergency physician-to-disposition time. This resulted in a statistically significant increase in length-of-stay in the ED for patients placed in the hallway. There were no discernible differences in return visits between hallway placement and traditional room assignment.

Hallway use may hasten access to treatment spaces, patients experience prolonged bed-to-emergency physician time and emergency physician-to-disposition times, leading to extended ED stays and potentially impacting outcomes and patient satisfaction. This prompts further investigation into the underlying causes and the development of strategies that optimize patient flow and enhance care delivery.

Possible Reasons Why

1. Our systems are overwhelmed: As previous studies have demonstrated, running our emergency system at capacity levels higher than 85-90 percent results in resources becoming overwhelmed and, as a result, increased boarding and hallway utilization.⁴ This ultimately leads to medical errors and threats to patient safety and privacy.
2. Implicit biases in health care: The disparities observed in the study, with males and patients on Medicaid or self-pay insurance being more likely to be placed in hallway beds, could be attributed to inherent biases within the health care system. Unconscious stereotypes or assumptions about specific patient populations can influence decision making, leading to differential treatment and bed assignment.
3. Barriers to accessing primary medical care: Limited access to timely primary care services may result in higher ED visits for lower acuity complaints. When these patients present to the ED, their lower acuity level may influence decisions regarding bed placement, making hallway beds suitable for less urgent cases.
4. Limited access to resources and monitoring equipment: Hallway beds often lack the equipment and resources that dedicated treatment spaces provide. This can lead to delays in providing specific procedures, pelvic exams, ensuring privacy, access to oxygen, suction, and other essential care.
5. Transient residents waiting for space: Junior or rotating residents sometimes may wait for a dedicated treatment area to take medical histories or perform procedures or interventions. This inadvertently prolongs the stay of patients in the hallway, unaware that their history or procedure can be conducted in the hallway itself.
6. Limited privacy and patient discomfort: The lack of privacy in hallway spaces can make patients feel uncomfortable and self-conscious. Patients may also find it harder to focus on their care because of the commotion and activity around them. Discussing sensitive medical information may become challenging, affecting the patient’s overall experience and future willingness to seek care. Ideally, any sensitive chief complaint should result in a private exam space for evaluation.

Hallway placement poses significant challenges and potential drawbacks. It’s crucial for hospital administrators and policymakers to challenge the common mantras that justify this practice. Instead, they should work toward finding comprehensive solutions prioritizing patient safety, privacy, and efficient care delivery. By addressing these issues head-on, we can strive for an ED environment that genuinely prioritizes the well-being and needs of every patient.

Possible Steps for Administration

Given the detrimental effects of hallway placement on ED efficiency and patient care, hospital administrators must take proactive measures to combat crowding. We recognize, of course, that much of ED crowding stems from increased hospital boarding, which ED leaders can’t solve. In the interim, we recommend the following steps:

1. Enhance resource allocation: Allocate sufficient resources, including staff, treatment spaces, and equipment, to meet the increasing demand in the ED. Implement effective triage systems to prioritize patients based on acuity and optimize the utilization of available resources.
2. Data-driven decision making: Leverage data analytics to identify patterns, bottlenecks, and areas for improvement within the ED. Regularly evaluate key performance indicators and employ evidence-based strategies to drive decision-making and quality improvement initiatives.
3. Redesign front-end flow: Consider implementing triage practices or standardized order sets for patients who are more likely placed in a hallway bed.
4. Staff support and well-being: Recognize the immense pressure ED staff face due to overcrowding and hallway care. Provide support mechanisms, such as sufficient breaks, access to mental health resources, and regular debriefing sessions, to mitigate burnout and promote staff well-being.

Hospital leaders must urgently address the burden of ED crowding and its effects on hallway care. They can create a more efficient and patient-centered emergency department by implementing strategic measures to enhance resource allocation, prioritize staff well-being, and embrace data-driven decision-making. Let‘s take action to optimize care delivery, support physicians, and improve patient outcomes.

Acknowledgment

Thank you to Arjun Venkatesh, Andrew Ulrich, Vivek Parwani, Reinier Van Tonder, Edieal Pinker, Beth Liebhardt for their support of this work and commitment to improving care of patients in the emergency department.

Mr. Su is a PhD candidate in Operations Management with a research interest in optimizing healthcare operations to enhance efficiency, fairness, and patient outcomes.

Ms. Meng is an assistant professor of operations management at the Yale School of Management at Yale University.

Dr. Sangal is an associate medical director of the Yale Adult ED and assistant professor of emergency medicine at Yale University.

Dr. Dilip is a second-year healthcare administration and leadership fellow at Yale University and completed her residency at Kings County/SUNY Downstate in Brooklyn, NY.

References

1. Feldman JA. When the aberrant becomes the accepted: The rise of hallway care in emergency medicine. Acad Emerg Med. 2020;27(3):256-258.
2. Bernstein SL, et al. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med. 2009;16(1):1-10.
3. Feiz A, Baker W. Limits of capacity flexibility: Impact of hallway placement on patient flow and quality of care in the emergency department. Social Science Research network website. Published October 22, 2021. Accessed November 28, 2023.
4. Janke AT, Melnick ER, Venkatesh AK. Hospital occupancy and emergency department boarding during the COVID-19 pandemic. JAMA Netw Open. 2022;5(9);e2233964.