Pandemic-Era Care Transitions Led to ED Overcrowding
By Melinda Young
Researchers found that adult patients who visited EDs in a North Carolina health system between March 1, 2020, and March 1, 2022, faced significantly longer stays if they were transitioned from the ED directly to a skilled nursing facility (SNF) instead of transitioning to a hospital bed and then to a SNF.1
Their length of stay in the ED was 72.8 hours. Patients who transitioned from the ED to a hospital bed and then to a SNF recorded a 14.5-hour length of stay. Besides spending days in less comfortable surroundings, the patients who remained in the ED until moving to a SNF often are less prepared for their transfer.
From the ED’s perspective, this resulted in people spending days in a place that was designed for helping patients in medical crisis. Their presence affected staff and resources that needed to be diverted to emergency patients.
“We spend a lot of time in the ED, and we started to notice elderly, long-stay patients in the ED waiting for SNF placement. This was unusual for us,” says Eugenia B. Quackenbush, MD, FACEP, study co-author and a clinical associate professor and clinical trials program director at the University of North at Carolina Chapel Hill department of emergency medicine.
Factors in Overcrowding
ED overcrowding with non-urgent patients can happen during natural disasters and when medical inpatient support is too limited for patients with mental health crises. But the pandemic also created this circumstance because of a change made by CMS with the COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers.1
Patients transferred directly from the SNF from the ED was a new pathway. “Previously, those who lived at home and were unable to safely return home for various health reasons were admitted to hospital for a mandatory three-day stay to qualify for nursing home placement,” Quackenbush explains. “I was concerned for the long stays these patients were experiencing and decided to study it further with my research group.”
The emergency declaration waived the standard requirement of a three-day qualifying hospital stay before SNF placement. It also waived the preadmission screen and resident review used to screen potential SNF patients for serious mental illness and/or intellectual disability. The screening is to ensure facilities can accommodate those patients.1
Because of the pandemic, the waiver, and hospital bed shortages, patients who needed post-acute support after an ED visit no longer had to stay in a hospital bed where they could be monitored and assessed before the transition to a SNF. Instead, they sometimes spent several days in the ED.
“We wanted to shine a light on this particular group of patients to bring attention and focus in hopes of improving the transition process,” Quackenbush explains. “They were boarded in the emergency department — which, from an emergency physician’s perspective, actually contributed to our boarding problem. This takes valuable resources and decreases our emergency department’s capacity for new patients.”
The ED-to-SNF group experienced a significantly longer ED length of stay when compared with the ED-to-inpatient-to-SNF group. “This was expected,” Quackenbush says. “I think the more interesting aspect is that we looked into granular parts of the ED visit, such as what sort of beds the patients were in, and how many times they were moved around the department.”
ED boarding is a national problem with many causes, including a shortage of beds, staffing, and outpatient resources. “When one patient is in a bed for a long period of time, it effectively makes the emergency department smaller, with less space and resources for those newly presenting and in the waiting room,” Quackenbush explains. “Any subset of patients who are boarding for long periods of time need to be studied to find tailored solutions.”
This problem continued through the pandemic. CMS did not drop the waiver until May 2023. “These were people who did not have what has traditionally been considered a qualifying diagnosis for an inpatient stay,” Quackenbush explains. “The easiest example would be if you had a patient with a hip fracture and needed operative treatment. It’s clear-cut they need admission for operative treatment, an inpatient stay, and then discharge to a skilled nursing facility for skilled rehabilitation.”
A patient of the same age who fell and sustained a fracture that did not require operative treatment but still could not ambulate well enough to be discharged home would not be admitted to the hospital. During the pandemic, that patient could be transitioned directly from the ED to the SNF.
“It’s very difficult,” Quackenbush says. “We have a very benevolent hospital, and every effort was made to accommodate people, but there simply weren’t enough beds. We had floors taken up by COVID admissions, and there was no place to put people.”
The ED was met with bed shortages in the hospital and in outpatient settings to which patients would otherwise be transferred. The pandemic affected staffing and hospital resources, and the ED was the hospital’s safety net.
No Quick Solutions
The problem is complex with multifactorial roots, and there are no easy solutions. “Working together in a multidisciplinary team can improve the care of these patients,” Quackenbush says. “Our case managers are an incredibly nimble group who responded quickly to the problem and streamlined their processes.”
The hospital dedicated significant resources for patient safety, and sitters were part of this solution. They were techs or nursing aides whose only job was to sit with patients and protect them in the ED, and they were available 24/7. “The hospital has devoted resources to assure dedicated case management services assigned to the ED,” Quackenbush adds.
Case managers identify at-risk patients early in the ED visit and conduct an initial assessment. They also establish a relationship with the patient and family and anticipate their needs.
“We have developed guidelines for physicians and nurses to make sure home meds, DVT [deep vein thrombosis] prophylaxis, hospital beds, and PT/OT services are ordered,” Quackenbush explains. “We used hospital beds for their stay, so they were not on a stretcher the whole time. We had sitters who could evaluate their fall risk and watch those who might wander.”
Even with additional safety measures, the ED is not an ideal environment for people who need nursing care. Patients would be in an area with lights on around the clock, and they lacked privacy. The ED space for patients has no windows, and patients are moved from one area to another often, which can be difficult for patients.
“It’s a vulnerable group who has a need for a more stable environment,” Quackenbush says. “I think housing them in the emergency department is problematic — and also is a boarding problem.”
Researchers wanted to investigate the problem, shine a light on it, and bring attention with the hope of finding solutions, such as using hospital beds and ordering their medications.
There are a few more things hospital EDs can do to reduce the strain on staff caused by long lengths of stay among patients. “The optimal strategy is some sort of observational unit with a dedicated staff,” Quackenbush says.
An observational unit could be a more comfortable place for patients. “I would be interested to see how the end of the CMS waiver in May 2023, with reinstatement of the three-day inpatient hospital qualifying stay, has affected these transitions,” Quackenbush says. “I am also interested in how other institutions have dealt with those making the transition from private dwelling to skilled nursing facility placement.”
- Tolentino AP, Gaus KS, Gao Y, et al. Transition of care from the emergency department to skilled nursing facility: Retrospective case-control study. J Am Coll Emerg Physicians Open 2023;4:e13022.
Researchers found that adult patients who visited EDs in a North Carolina health system between March 1, 2020, and March 1, 2022, faced significantly longer stays if they were transitioned from the ED directly to a skilled nursing facility (SNF) instead of transitioning to a hospital bed and then to a SNF.
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