Calling ED Boarding a Public Health Crisis, ACEP Pushes Policymakers to Act
By Dorothy Brooks
Too many EDs are bursting at the seams with patients who have been admitted but languish in the emergency setting for hours, days, or even weeks before they are moved to an inpatient bed. That is the message the American College of Emergency of Physicians (ACEP) is urgently sending to policymakers, saying the situation with ED boarding has become a public health crisis.
To highlight the urgency of the problem, ACEP spoke at length with reporters and stakeholders about the problem in a briefing on Oct. 3, 2023. “Emergency departments are really overflowing with patients, [and there is] nowhere to actually put those patients after the decision is made that they need to stay in the hospital,” stressed Aisha Terry, MD, MPH, FACEP, president of ACEP. “Our emergency physicians are certainly overwhelmed with just too many patients, and truly this is putting patients at risk.”
While ED boarding is hardly a new phenomenon, Terry noted the scope of the problem has expanded — along with new concerns, consequences, and even causes. “In the past, hospitals and healthcare systems have tended to prioritize maintaining inpatient capacity ... and less focus has been put around staffing and resources,” Terry said. “We’re coming to a point where that lack of attention in the past is really impacting our ability to provide care today.”
Terry explained that in the wake of the COVID-19 pandemic, unprecedented staffing shortages are putting a unique strain on EDs because they generally are not subject to the same staffing ratio requirements as other parts of the hospital. She also cited misaligned financial incentives as part of the problem. For example, Terry described situations in which there may not be a bed available for an admitted ED patient because that bed may have been assigned to a patient arriving for an elective surgery. “We know that the reimbursement rate from insurance companies tends to be higher for elective surgeries [than for] patients who come into the emergency department,” Terry explained.
Mental Health Crisis Drives Boarding
Another big contributor to the boarding crisis is the lack of resources to care for patients with mental health issues, said Terry, noting it tends to be harder to find an adequate inpatient bed for patients with mental health concerns. Indeed, just ahead of the annual conference of the Emergency Nurses Association (ENA) in San Diego, in September, Terry Foster, MSN, RN, CEN, CPEN, CCRN, TCRN, FAEN, the president of ENA, said the mental health crisis in the United States is perhaps the largest contributor to boarding in EDs.
“ENA research shows that the average emergency department stay for a behavioral health patient is 18 hours compared to four hours for all other types of patients,” said Foster during an ENA town hall event preceding the conference on Sept. 20, 2023. “Many patients visit the emergency department due to the lack of behavioral health resources in the community.”
Speaking at the ACEP briefing, Laura Wooster, MPH, senior vice president of advocacy and external affairs at ACEP, noted the lack of mental health resources is particularly acute for the rising number of children who present to EDs with mental health concerns. “They seem to have the longest boarding times, and that is partially due to the workforce challenges [related to] specialized care for these patients,” Wooster said.
She observed that one of the reasons for this is the supply of people with the training to care for pediatric patients with mental health concerns is even tighter than the supply of personnel who care for adults with such issues.
Regardless of the cause, researchers have repeatedly documented adverse consequences from ED boarding, according to Terry. “[These] can include worse outcomes, medical errors, privacy compromises, and even in some cases, death,” she observed. “This is about patients who are seeking care for their emergencies. We know that when you have a healthcare need, you need to get that care as soon as possible.”
To engage with the public, ACEP teamed with Morning Consult in September to survey adults about the problem. In a sample of 2,164 adults, 80% said they were concerned about the boarding crisis, with 44% indicating they or a family member had experienced prolonged waits after they were seen in the ED but before they were admitted or transferred.
Furthermore, 16% of adults who had experienced a long wait time indicated they waited 13 hours or longer. Notably, this is far outside guidance from The Joint Commission, which indicates ED boarding should not exceed four hours.1
When asked about potential solutions, nine out of 10 respondents said additional or supplemental government funding for emergency medicine services should be a priority. The largest share of respondents (42%) indicated hospitals should be primarily responsible for improving boarding and shortening wait times. Another 17% indicated Congress should solve the issue through legislation, and 16% said insurance companies were to blame because of their time-consuming prior authorization policies that can delay the transfer of ED patients to skilled nursing facilities.
While ACEP is sounding the alarm about the boarding crisis, Terry stressed it is not a problem emergency care providers can solve alone. “Not a single hospital or even medical system can come up with meaningful solutions to boarding alone,” she said. “We really need the help of policymakers.”
Thus, ACEP is pushing for passage of several pieces of legislation that could alleviate some elements of the boarding crisis. These include:
• H.R. 5414: Improving Mental Health Access from the Emergency Department Act of 2023
• H.R. 2412: Helping Kids Cope Act (https://bit.ly/3Qmahae).
• H.R. 5804: Mental Health Infrastructure Improvement Act of 2023 (https://bit.ly/48SlE0K).
• H.R. 4941: Promoting Access to Treatment and Housing (PATH) Act (https://bit.ly/48Zov86).
Other changes ACEP is advocating include improved transparency and information-sharing, alleviated regulatory burdens, and greater support for healthcare workers regarding tuition reimbursement as well as mental health and suicide prevention, according to Terry.
The added support for healthcare workers is needed because the boarding crisis is not just creating adverse consequences for patients; it also is contributing to provider burnout. “Unfortunately, we sometimes feel helpless when we see patients get preventable illnesses and, in some instances, even die because hospitals cannot keep up with the number of patients who need care,” Terry said.
Life for an emergency physician is stressful and challenging, and boarding just piles on the stress. “There are already existing challenges we’re dealing with ... and [boarding] certainly amplifies staff shortages,” Terry said.
ACEP understands alleviating the boarding crisis will require collaborative solutions. “There are institutional challenges. We know that in order to address those challenges, there really has to be a systemwide solution,” Terry said. That is why on Sept. 27, 2023, in Washington, DC, ACEP convened what Terry described as a national summit of stakeholders across the healthcare continuum to at least start the discussion about potential solutions to the ED boarding problem.
“We had representatives at this summit from hospitals, nursing homes, EMS, government agencies, policymakers, patient groups, and mental health clinicians,” she reported.
For five hours, the group discussed the barriers to ED boarding solutions and next steps in terms of coming up with new approaches to the problem. “We had everyone at the table in terms of decision-makers and the right people to really come up with some meaningful change around boarding,” Terry said.
- The Joint Commission. Patient flow through the emergency department. R3 Report. Dec. 19, 2012.
Too many EDs are bursting at the seams with patients who have been admitted but languish in the emergency setting for hours, days, or even weeks before they are moved to an inpatient bed. That is the message the American College of Emergency of Physicians is urgently sending to policymakers, saying the situation with ED boarding has become a public health crisis.
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