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From “A Campfire to a Forest Fire”: The Devastating Effect of Wait Times, Wall Times and Emergency Department Boarding on Treatment Metrics

2022; Elsevier BV; Volume: 81; Issue: 1 Linguagem: Inglês

10.1016/j.annemergmed.2022.11.011

1097-6760

Alan Huffman,

Healthcare cost, quality, practices

As Americans look hopefully toward the end of the pandemic, many aspects of life are returning to normal, including routine health care. Still abnormal, though—and likely to remain so, are wait times for emergency care, which grew perilously long during the pandemic because of staff shortages and patient overload. “Patients will suffer with that in the short term,” observed Arjun Venkatesh, MD, MBA, associate professor and administration section chief at Yale School of Medicine’s department of medicine. “It will take years to layer in the necessary changes. I doubt next year you’ll be reporting that things have improved. I hope we’ll be improving, but there are not that many people to staff the emergency departments (EDs) out there. There are shortages everywhere.” The shortages go beyond frontline clinicians, Venkatesh said. “You wish you had more of everything—not only doctors and nurses but an extra tech, everyone down to the cafeteria worker.” The absence of even secondary positions can lengthen timeframes, such as by slowing the delivery of patient meals, which causes ripple effects on their care. “We’re seeing unique cracks in every link in the chain,” he said. Venkatesh is a coauthor of a pair of Yale studies released in September 2022 that document widespread and increasing crowding and understaffing in EDs, leading to wait times as long as 6 hours, which can put lives at risk.1Locklear M. Emergency department crowding hits crisis levels, risking patient safety. YaleNews.https://news.yale.edu/2022/09/30/emergency-department-crowding-hits-crisis-levels-risking-patient-safetyDate accessed: November 10, 2022Google Scholar The studies, based on data from 2020 to 2021, found that patients were twice as likely to leave EDs before seeing a physician in 2021 compared with 2017 and spent an unsafe number of hours in hospital hallways awaiting a bed. That is particularly concerning for patients who need care for critical issues such as strokes, sepsis, heart attacks and other cardiological issues, and trauma. The pandemic exacerbated delays, but it’s inaccurate to say it caused them, Venkatesh said. “We always had a fire going, but it was a campfire. Now it’s a forest fire,” he said. In one of 2 articles about the studies reported in JAMA Network Open, Venkatesh and his fellow researchers noted “the failure of the emergency care system to maintain broad access in the context of pandemic demands” and concluded that “existing regulatory and financial incentives may be inadequate to meet challenges of future pandemic waves and other disasters.” 2Janke A.T. Melnick E.R. Venkatesh A.K. Monthly rates of patients who left before accessing care in US emergency departments, 2017-2021.JAMA Netw Open. 2022; 5e2233708Crossref Scopus (6) Google Scholar In their analysis3Janke A.T. Melnick E.R. Venkatesh A.K. Hospital occupancy and emergency department boarding during the COVID-19 pandemic.JAMA Netw Open. 2022; 5e2233964Crossref Scopus (11) Google Scholar of the databases, the researchers found that when hospital occupancy was above 85 percent, ED boarding typically exceeded the 4-hour duration considered safe by the Joint Commission, which sets standards for hospitals. Boarding overall increased through 2020 and 2021, though hospital occupancy did not rise beyond January 2020 levels. “The harms associated with ED boarding and crowding, long-standing before the pandemic, may have been further entrenched,” another of the studies’ coauthors, Alexander Janke, MD, MHS wrote. Continuing staff shortages and other ED issues are thwarting efforts to reduce the delays, even in cases where minutes can directly influence clinical outcomes. Of the top 5 critical care areas of concern, Venkatesh said, “The one I worry about the most is sepsis. You can be heroic with strokes and heart attacks, which are easier to diagnose. CT scans and EKGs can be done in minutes. Sepsis is a very difficult diagnosis to make, and it can smolder and then suddenly get worse.” A fact sheet provided by the Sepsis Alliance, an educational and advocacy group, notes that sepsis is a medical emergency that requires rapid treatment for survival. Sepsis, according to the alliance, is the leading cause of death in US hospitals, representing 35 percent of mortalities, and the risk increases between 4 and 9 percent for every hour of delay in treatment. About 80 percent of septic shock patients can be saved through rapid diagnosis and treatment, according to the alliance. Emergency department wait times are not categorized by a specific medical issue, and they vary significantly, but delays generally decreased between 2012 and 2017 and afterward increased until early in the pandemic, when they again temporarily decreased as a result of patients avoiding ED visits. They have since been ratcheting up again. “It wasn’t this bad during the worst of the pandemic,” Venkatesh said. “Historically, when we think of boarding times it’s about trying to reduce boarding in the ED. The problem was people being kept too long in the hospital. It’s different now. What we’re seeing is a macro issue: We don’t have enough staff at every level.” Staffing levels at primary care facilities, nursing homes, and home care are currently at around 50 to 60 percent, he said. “The big problem is that the pandemic has raised the cost of delivering health care, and with less money, people are being laid off. There’s also this massive situation—if you want to call it the great resignation—where we just don’t have enough workforce. And the ED is the safety net. We’re shunting all health care needs to the ED, and there aren’t enough resources in the ED.” A Centers for Disease Control and Prevention fact sheet reported that mean ED wait times in 2016 ranged from 24 to 49 minutes, depending on patient volume.4National Health Care SurveysCenters for Disease Control and Prevention.https://www.cdc.gov/nchs/about/factsheets/factsheet_nhcs.htmDate accessed: November 10, 2022Google Scholar In 2017, The New York Times reported, patients waited on average approximately 40 minutes, down from about an hour a decade before.5Frakt A. Improve Emergency Care? Pandemic Helps Point the Way. The New York Times.https://www.nytimes.com/2020/11/23/upshot/pandemic-telemedicine-emergency-care.htmlDate accessed: November 10, 2022Google Scholar By late 2021, the newspaper reported that staff shortages resulting from “burnout and poaching by financially flush health systems” had led to longer wait times and “the worst public health crisis in living memory.”6Jacobs A. ‘Nursing Is in Crisis’: Staff Shortages Put Patients at Risk. The New York Times.https://www.nytimes.com/2021/08/21/health/covid-nursing-shortage-delta.htmlDate accessed: November 10, 2022Google Scholar Overall numbers sometimes shroud even more extreme delays. According to one report, the median ED wait time in California during 2017 was more than 5½ hours for patients who were admitted to the hospital.7Reese P. As ER wait times grow, more patients leave against medical advice. Kaiser Health News.https://khn.org/news/as-er-wait-times-grow-more-patients-leave-against-medical-advice/Date accessed: November 10, 2022Google Scholar The comparable median length of a stay nationwide was 80 minutes shorter during the period, although 4 states had longer median wait times than California. Another study published in September 2022 found that the number of patients visiting EDs during one month in 2020 had declined 42 percent from the same period a year before as a result of the pandemic.8Woodruff A. Frakt A. COVID-19 Pandemic leads to decrease in emergency department wait times.JAMA Health Forum. 2020; 1e201172Crossref PubMed Scopus (8) Google Scholar But wait times then began to grow, according to a report from February 2022, which relied on data from 2020 and part of 2021 and found that the shortest median wait time by state was 104 minutes, with the longest about 228 minutes.9Gooch K. ER wait times, by state. Becker’s Hospital Review.https://www.beckershospitalreview.com/rankings-and-ratings/er-wait-times-by-state.htmlDate accessed: November 10, 2022Google Scholar If the ED is short-staffed, ED workers cannot simply drop everything—they have other patients to treat. For stroke, treatment time metrics are typically referred to as “door-to-needle,” representing the time between arrival and the administering of thrombolysis drugs. Many procedures have to be completed during that window. In addition to consultations about medications and general medical history, patients need intravenous infusions and computed tomography scans. Delays are particularly risky because neurons are dying. The common adage is, “Time is brain.” Specific risks include more dead brain and poorer overall recovery. Guidelines recommend a median door-to-needle time of 45 minutes. However, studies have found that less than 60 percent of eligible US patients are treated within this window. Evidence also suggests disparities in timely treatment in patients who are older, African-American, or female. In cases involving myocardial infarction, the metric is door-to-balloon time. The primary risk, in addition to sudden death, is myocardial damage. For sepsis, the metric is “door-to-antibiotic.” Patients whose treatment is delayed are more like to die, and the survivors have worse long-term outcomes. For all of these medical emergencies, the risk of death increases with treatment delays. Venkatesh offered as an example a patient with congestive heart failure. “The cardiologist’s office is understaffed,” he said, “so they get a short telemedicine appointment, but the local radiologist has a long wait, so they go to the ED, where there’s another long wait, and maybe they don’t have a ride that can wait with them, and they might leave without being treated, and when they come back, by this point everything has been so delayed that they have breathing problems, and it develops into a full cardiac issue. Then they wait in the hospital for home care or because there’s a nursing facility shortage, which exposes them to hospital pneumonia. Across the nation, there are so many people in this tension.” Added to that, hospitals are closing, partly because of pandemic financial stresses, “So we’re cramming more and more people into less space.” Venkatesh cited a recent report on patient boarding times in the United Kingdom that found each hour spent in the ED increased the likelihood of death. “That’s in the United Kingdom, but there’s no reason to think it would be any different here,” he said. The Yale studies relied on electronic health records from participating hospitals (1,289 in January 2020, up to 1,769 by December 2021). When occupancy exceeded 85 percent, the median ED boarding time was 6.58 hours. Median ED boarding time overall was 2 hours in January 2020, which decreased to 1.58 hours in April 2020. In December 2021 it went up to 3.42 hours. Researchers found that median hospital occupancy was highest in January 2020, then dropped to its lowest point in April 2020 before gradually rising and leveling off at the end of 2021. Then came an inexorable uptick. Rebecca Cash, PhD, MPH, coauthor of a study published in American Heart Association Journals in February 2022 that looked at prehospital time intervals for suspected stroke patients who were treated and transported by emergency medical service (EMS), responded to questions about stroke specifics and associated delays by email.10Cash R.E. Boggs K.M. Richards C.T. et al.Emergency medical service time intervals for patients with suspected stroke in the United States.Stroke. 2022; 53: e75-e78Crossref PubMed Scopus (4) Google Scholar “Anecdotally, at least, ED length of stay and EMS ‘wall time’ (aka offload time, the time from arrival at the ED to moving a patient into an ED bed) have increased, likely because of crowding and boarding of patients”, she wrote. “For time-sensitive conditions, like stroke, usually the ED has a process to begin immediate assessment and treatment, bypassing the wait for a bed. That might include the EMS crew taking the patient, on their stretcher, directly to CT.” Cash, an assistant professor of emergency medicine at Harvard Medical School, cited time limitations for certain approaches to treating stroke. “For example, traditionally, the window for treating an acute ischemic stroke with IV medication (such as tissue plasminogen activator, or tPA) is 4.5 hours from last known well. For endovascular thrombectomy, a surgical procedure, it is about 6 to 24 hours from last known well. But that’s why timely diagnosis and treatment of stroke is so important, and meeting certain hospital metrics like door to imaging and door to needle are stressed—if the patient is outside of the treatment window, the chance of survival and/or full recovery is much lower.” The ED delays also back up the EMS system. Wall times, according to Cash, “appear to be getting longer because there are no places to put EMS-transported patients in the overcrowded EDs. Especially patients requiring monitoring/care that can’t sit in the waiting room for a few hours. Increased wall times are not new; this has been going on far longer than the pandemic, but the pandemic exacerbated the problem. It’s a domino effect—there are no inpatient beds available, so admitted patients board (stay in the ED) until a bed opens up, so ED patients waiting for care have no place to go, so EMS can’t offload the patients they bring.” The problem of increasing ED delays is not unique to the United States. The New York Times reported in September 2022 that nursing staff shortages had shut down EDs across Canada and forced some patients to wait days for a bed. Another article reported in October 2022 that a London hospital was forced to shut down its ED after wait times exceeded 18 hours.11Isai V. ‘Disaster Mode’: Emergency rooms across Canada close amid crisis. The New York Times.https://www.nytimes.com/2022/09/14/world/canada/nurse-shortage-emergency-rooms.html?smid=tw-nytimesworld&smtyp=curDate accessed: November 10, 2022Google Scholar,12Bieman J. Long weekend, long ER waits: LHSC working to reduce 18-hour wait. The Londoner.https://www.thelondoner.ca/news/local-news/long-weekend-long-er-waits-lhsc-working-to-reduce-18-hour-wait/wcm/2dc4dcb3-f455-448e-b39f-45369497494f?utm_source=rss&;utm_medium=feed&;utm_campaign=truncated_content&;utm_content=news_local-news&;utm_term=jennifer_biemanDate accessed: November 10, 2022Google Scholar The American Nursing Association (ANA) projects that nursing shortages will persist, in part, because of pandemic burnout but also because many nurses are subject to unsafe staffing ratios.13Nurses in the Workforce. American Nurses Association.https://www.nursingworld.org/practice-policy/workforce/Date accessed: November 10, 2022Google Scholar The ANA wrote to the US Department of Health and Human Services in September 2021 urging the agency to declare the “unsustainable” nurse shortage a national crisis.14ANA urges US department of health and human services to declare nurse staffing shortage a national crisis. American Nurses Association.https://www.nursingworld.org/news/news-releases/2021/ana-urges-us-department-of-health-and-human-services-to-declare-nurse-staffing-shortage-a-national-crisis/Date accessed: November 10, 2022Google Scholar By 2025, US News & World Reports reported in July 2022, the US is expected to be short more than 400,000 home health aides, nearly 100,000 nursing assistants and an equal number of medical and laboratory technologists and technicians, and about 30,000 nurse practitioners.15Johnson S.R. Staff shortages choking U.S. health care system. U.S. News & World Report.https://www.usnews.com/news/health-news/articles/2022-07-28/staff-shortages-choking-u-s-health-care-systemDate accessed: November 10, 2022Google Scholar Cash noted the problem “is multifaceted—not just EMS, but also related to processes, staffing, and resources in the ED, hospital, larger health care system… and, of course, the public.” The American Ambulance Association has a wall-time toolkit, which provides advice to emergency medical technicians (EMTs) regarding hospital-related delays.16Wall Time Toolkit. American Ambulance Association.https://ambulance.org/2022/01/28/wall-times-toolkit/Date accessed: November 10, 2022Google Scholar The toolkit notes that when EMS providers are kept out of service for extended periods of time because they are unable to transfer patient care at the hospital, “wait times for both 911 and inter-facility patients increase, and both emergency and nonemergency calls pile up.” The toolkit advises EMT providers and staff to “engage the hospital leadership to collaborate to identify possible solutions. Often, we assume that the hospital leadership is aware that the EMS crews are being held for extended periods of time.” Because hospitals may not be cognizant of the breadth of the impacts, the toolkit advises EMT organizations to remind hospital administrators of their obligations under the Emergency Medical Treatment and Labor Act,17Emergency Medical Treatment & Labor Act (EMTALA)Centers for Medicare & Medicaid Services.https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALADate accessed: November 10, 2022Google Scholar and to consider “placing a transfer coordinator or another member of your staff to stay with patients during the transition between EMS and ED care.” EMS providers have no obligation to do the latter, and it “could set a precedent or expectation by the hospital that extended APOT [ambulance patient offload time] is the EMS agency’s responsibility,” according to the website. “However, it may serve to free up valuable EMS resources.” The National Association of EMS Physicians website18COVID-19 Town Halls. National Association of EMS Physicians.https://naemsp.org/resources/covid-19-resources/covid-19-town-halls/#OvercrowdingDate accessed: November 10, 2022Google Scholar notes that EMS systems “are experiencing unprecedented challenges in providing ambulance availability. Some of this appears directly related to the lingering effects of the pandemic on staffing and, more recently, overwhelmed hospital systems have no place to put our patients[,] leading to extended ‘wall times’ for our crews. NAEMSP is convening a series a Town Halls to bring together a geographically diverse group of EMS leaders to discuss the current state of affairs and approaches they have taken to deal with the crisis.” Others had called for more extreme measures, including penalizing hospitals financially for long wait times, as the authors proposed in this article19Savva N. Tezcan T. To reduce emergency room wait times, tie them to payments. Harvard Business Review.https://hbr.org/2019/02/to-reduce-emergency-room-wait-times-tie-them-to-paymentsDate accessed: November 10, 2022Google Scholar from 2019 in Harvard Business Review, at a time when wait times were becoming increasingly controversial yet were shorter than they are today. The authors recommended tying a portion of hospital payments to the national average wait time of ED patients with similar conditions. To solve the problem, Venkatesh said, the health care system as a whole “needs a once-in-a-lifetime solution. It will take decades to train more nurses and doctors, so we have to figure out how to maximize the staff we have. Use AI [artificial intelligence] and other technology to do jobs like dealing with clerical issues and insurance, and put people in the critical jobs.” As it is, he said, critical care staff are often encumbered with minor tasks, and if those were lifted, “Maybe each person could take care of more patients. Right now, the focus of all our money is on patients at the sickest level. We need to redesign payment systems.” He said some of these efforts are being considered or put in place, “but it will require 20 hard solutions, and health care doesn’t pivot quickly.”