As the literal and figurative front door of many hospitals, the emergency department can provide a glimpse into the future of hospitals. And that future is, in a word, a stalemate.
The number of emergency room visits has been rising faster than population growth for more than a decade and now stands at 150 million a year. In the same period, the recording capacity decreased by 27%
The emergency department has been in trouble for some time. In 2007, the Institute of Medicine report, “Hospital-Based Emergency Care: At the Breaking Point,” noted that 90% of emergency departments noticed extreme stress at some point during a year.
While this stems in part from inefficient internal surgeries, the most common reason for overcrowding is the inability to get emergency patients to a hospital bed because there are no empty beds to send them to. Covid-19 has not caused this overpopulation as this problem has been going on for over a decade, but it has certainly complicated the situation.
The real cause behind the shortage in emergency departments is clearly in demographics. While 8,000 65-year-olds sign up for Medicare every day, they use the emergency room at about the same rate as those in the 50 to 60 age group. That changes with age:
The first baby boomers will reach the age of 75 in 2021. As the number of births increased each year from 1946 to 1964, peaking in the late 1950s, the number of 75-year-olds will not peak until 2039. is that the life expectancy of these individuals is longer than that of their predecessors – about a third of all women alive today will live to be 90 or older, meaning this group will be in the 75-year-old age group for at least 15 years. and will be older.
A recent article on the emergency physician workforce predicted an increase in emergency room visits due to the growth of the U.S. population, especially among those over the age of 75.
While the above trends are well known, these predictions and the discussions surrounding them were too narrow in their view of hospital service demand, neglecting what “demand” really means in this area.
When older persons come to an emergency department, they generally stay longer than younger persons because they have more problems and these problems are more complex and take more time. So the measure of demand should not be “visit”, but “operate” – how long a person occupies a bed of an emergency department, reducing its capacity.
Older patients are also more likely to be hospitalized.
The same phenomena are duplicated on the clinical side. Older patients tend to be sicker and need more attention; longer stays reduce capacity. A Massachusetts hospital recently noted that hospital ward length of stay had increased by nearly a full day, resulting in an overall capacity reduction of about 15%. With a stay of six days, one bed can accommodate 60 patients per year; with a seven-day stay, it can only accommodate 52 patients per year.
These blocks reverberate in two directions for hospitals: On the input side, hospitals may need to transfer emergency patients who need to be admitted to the hospital but can’t because there’s no room for them. On the output side, more elderly patients are unable to go home after their needs are addressed in the hospital, as they may need rehabilitation or nursing home care, but these facilities are already full or do not have enough trained staff – or both – to care for them.
Hotel operators have known for a long time that they cannot operate at 100% occupancy. There is no “flex time” related to people getting in and out, with a figure of about 94% being the maximum. Hospitals today often have rates of 100% or more.
Unless the capacity of emergency departments and their hospitals is expanded, the number of patients cared for in ED corridors (also known as boarding facilities) and in hospital ward corridors (the relatively new practice of ED workers who were initially cared for in beds) will increase. along the corridors of nursing wards) will inevitably grow. Above this practice hangs a collection of high-quality research that shows that the care that patients receive is substandard. Some of the reasons are obvious, such as deficiencies in monitoring patients’ status and treatments, along with serious declines in the patient experience, such as something as basic as going to the toilet. Others are not so obvious, such as patients in corridor beds who don’t get the thorough examinations they need and delays in making care plans for their inpatient stays.
Space planning is extraordinarily complex. If an emergency department or hospital ward is planned to house X patients being cared for by Y staff, and there are more than X patients, where do the extra staff work? The drug prep room now has more people trying to get drugs at the same time and waiting for computer access to log in the drugs. People in beds in the hallway are breaking basic fire and safety rules. And it’s essential to ask, “How many patients can a healthcare team properly care for at the same time?”
There is a maximum above which performance declines – and with it morale.
Research conducted by several colleagues and I showed that improving overcrowding in emergency departments and hospitals will require a 90% expansion of ED capacity by 2050 and 72% more room for hospital beds. While the birth rate has been falling lately, immigration is exceeding demographers’ expectations, making it likely there won’t be a surplus of beds after the influx of baby boomers to emergency departments and hospitals peaks in 2040.
Building new or expanded emergency departments will not solve the overcrowding problem unless clinical capacity is also expanded. The time lag between the decision to build new capacity and capacity becoming available is five years, and the pre-Covid cost for such an expansion was approximately $1 million per bed for both emergency and hospital beds. Those costs are higher today: new facilities would be subject to expensive design improvements, such as those for infectious disease management, and spikes in raw material and equipment costs have made construction more expensive.
Hospital-led home care is a new model that is now being evaluated in small programs. It has many attractive features, but is inefficient in some ways – for example, there are few nurse visits per day compared to what nurses can do when patients are pooled.
Some emergency departments have been able to identify patients who need more testing before discharge and, instead of admitting them to the hospital, care for them in observation units for less than 24 hours. There may be a cohort of patients whose care lies between emergency observation and full admission.
It’s possible that community-level hospitals could expand into new facilities that are easier, cheaper to build and get online faster, but this expansion could account for perhaps 25% of patients knocking on doors to get beds in existing facilities. to get.
Tent hospitals may be another option. These are usually built on hospital grounds, but have also been built in arenas. Such basic models can be transformed into permanent buildings that are cheaper and faster to build than traditional hospitals. For example, in the early days of the Covid-19 pandemic, China built two hospitals with more than 500 beds in 10 days. These were of basic functionality to deal with epidemics, but could serve as models for future expansion of US emergency and hospital capacity.
Of course, expanding the physical capacity of emergency departments and hospitals will require more caregivers. Any plan should therefore include staff development. This could be even more challenging than planning for physical capacity, with a looming shortage of doctors, nurses and other health professionals before the pandemic broke out and the fact that healthcare careers are less attractive now than they were two years ago.
No one wants to be cared for in the hallway of an emergency department or hospital, and hospital staff don’t want to provide care they know is inferior. The argument for expanding the facilities is indisputable – and the discussion of how this is conceived, built and operated should have been a “day 1” priority.
Anyone who plays a supervisory role in local health care should be required to spend 12 hours in an emergency department in their jurisdiction from 3 p.m. to 3 a.m., seeing parents on stretchers in the hallway, not before hours, but for days.
Stephen Bohan is a retired emergency medicine physician who worked at Brigham and Women’s Hospital in Boston and was an associate professor of emergency medicine at Harvard Medical School.