As ER overcrowding worsens, a program helping to ease the crisis may lose funding
Category: News & Politics
Via: perrie-halpern • 11 months ago • 45 commentsBy: Erika Edwards and Anne Thompson
S E E D E D C O N T E N T
As emergency room doctors nationwide plead for help to ease patient overcrowding, the one federal program that could fix the crisis is poised to lose funding.
Across the U.S., ER patients who need to be hospitalized find themselves stuck in hallways or waiting rooms, sometimes for days or weeks, before they are able to get further care.
Marissa Long, 30, spent three days and four nights on a gurney in a busy Los Angeles ER hallway last March, separated from other sick patients just a few feet away by a thin fabric curtain.
Long, a heart transplant recipient, was showing signs of possible organ rejection: trouble breathing and falling blood pressure. She needed to be admitted to the hospital, but there were no beds available.
"People were coughing and vomiting," Long said. "I already have a low immune system. I was scared to get sick."
Last summer in Bangor, Maine, Michael Day had heard of ER hallways full of sick patients, hacking and sneezing; people left sitting for days on hard, plastic waiting room chairs.
He did not want to go to the emergency room, although the 75-year-old had no choice. Following a diagnosis of advanced esophageal cancer, he was rapidly declining. He was weak and jaundiced. His blood pressure was plummeting.
With no available room in the hospital, Day found himself stuck in the ER, twice.
On one visit, Day developed a bed sore from remaining stationary for more than 26 hours. During another, the ER staff started him on an IV to replenish his fluids and hooked him up to a blood pressure monitor while he waited to be seen by a doctor.
Once again, hours ticked by.
Day's wife, Kathy — a former ER nurse — said they were there so long that the batteries in her husband's blood pressure monitor eventually died. His IV ran out and dried up. The staff on duty, Kathy Day said, did not notice.
At that moment, Kathy Day uttered the sentiment echoed by countless ER patients across the country: "This is bulls---."
ER patients waiting for beds that don't exist
Emergency medical care is meant for one of two things: Treat a person quickly and send them home — stitch up a deep cut, perhaps, or determine that a high fever isn't a life-threatening infection, for example; or get the patient admitted into the hospital for further care.
Because America's health care system as a whole is woefully understaffed to care for an aging population rife with chronic illnesses, or to meet increasing needs for mental health services, patients show up in the ER and, without any place else to go, stay in the ER.
"There are fewer nursing home beds. There are fewer rehab beds. There are fewer psychiatric beds," said Dr. Ali Raja, deputy chair of emergency medicine at Massachusetts General Hospital in Boston. "Our overall length of stay for inpatients has gone up. Since those patients are staying longer in the hospital, we end up having more boarders in the emergency department."
Ninety-seven percent of ER doctors said they experienced patient boarding times of more than 24 hours, according to a November 2022 survey by the American College of Emergency Physicians.
More than a quarter, 28%, of the ER doctors said patients were forced to stay in the ER for more than two weeks before getting a hospital bed.
"There have been instances where patients are literally waiting for several weeks to months," Dr. Aisha Terry, president of the American College of Emergency Physicians, said during a briefing in October with reporters. "Patients are leaving early, or dying waiting."
Rising health care costs have forced health systems nationwide — often in rural areas — to shutter hospitals and other medical facilities in recent decades, according to the American Hospital Association. Elder care centers have also been affected, especially during the pandemic. A report from the Bureau of Labor Statistics shows that the number of workers in nursing homes and other care facilities fell by 410,000 between February 2020 and November 2021.
Dr. Joseph Tennyson, president of the Massachusetts chapter of the American College of Emergency Physicians said he recently worked an ER shift in which he had patients on oxygen support "waiting hours for an ICU bed that didn't exist."
Raja said his ER has been operating at a level dubbed "capacity disaster" — with at least 45 patients boarded at a time — for at least a year. On Jan. 11, the Massachusetts General Hospital ER reached an unfathomable level of boarded patients: 103. The situation prompted the hospital to ask its state health department to approve an extra 94 beds to ease the overcrowding.
"We don't have a clear solution," Raja said.
On Jan. 15, 229 people across the state were boarded and waiting to get a hospital bed, according to the Massachusetts chapter of the ACEP. For comparison, on Jan 17, 2022, during the Covid omicron surge, 278 people were boarded. Neither of those numbers include patients waiting for space to free up on a psychiatric care floor.
Massachusetts is unique in that it keeps very good statistics on the number of people waiting for hospital beds. Many states do not.
Dr. Doug Jeffrey, president-elect of the Texas College of Emergency Physicians, said the situation — which affects ERs across the country — has "gone from our typical organized chaos to an out-of-control crisis."
"We're treating people in the waiting room. We're treating people in the hallways. It's unsafe for patients," Jeffrey said.
Michael Day made several trips to the ER before passing away on Aug. 7. While his cancer was terminal, his wife Kathy, who worked 53 years as a nurse, is convinced that his condition worsened because of the delays in care.
"This is not patient care," Day said. "It's more like warehousing."
Hospital care at home
ER boarding has reached such a crisis point that some hospitals have begun to invest in a promising solution to ease the overcrowding crisis.
A federal program called "Acute Hospital Care at Home," or Hospital at Home, is designed to free up hospital beds, allowing patients to recover in their own beds. It was started by the Centers for Medicare and Medicaid Services in 2020 to help ease hospital strain during the pandemic.
In the program, people who are sick enough to be hospitalized — but well enough to do basic daily activities, such as walk safely to a bathroom — are able to be cared for in their own home, with round-the-clock remote monitoring and twice-daily visits from medical personnel. The average length of "stay" is four days.
Florence Sparks, 80, of Pineville, North Carolina, jumped at the chance to be treated at home rather than stay any longer in an ER. Sparks was having trouble breathing on Jan. 15 and had already spent 17 hours in an emergency department.
Sparks has congestive heart failure — a condition in which the heart doesn't pump blood effectively — and it was clear that she needed more care than the ER could provide.
Instead of waiting for an in-patient hospital room, her doctors utilized the Hospital at Home program, run by Atrium Health in Charlotte.
A community paramedic checked in on Sparks twice a day, adjusting her IV and her medications as needed — all in collaboration with her doctor.
Atrium Health says it's managing up to 60 patients a day in North Carolina through its Hospital at Home program, and aims to treat 100 patients daily by the end of 2024. Within the next 18 months, organizers project the program will free up 10% of their in-patient hospital beds.
"If we did not have Hospital at Home, there's no doubt in my mind, we would have people with longer delays for getting out of emergency departments," said Matt Anderson, senior medical director, Virtual Health at Atrium. "We know that there's strain."
Sparks was able to sleep in her own bed while getting hospital-level care.
"I think they're more attentive," she said. "They're not rushed to see another patient. They give you their undivided attention."
Colleen Hole, a registered nurse and head of Atrium Health's Hospital at Home program, called it "the model for the future" and said it could help reduce costs up to 25%.
"It's proven to be a model that works for our patients and works for our health system capacity challenges," she said.
At least 311 hospitals in 37 states have been approved to set up the program, although it's unclear how many are actually using it, according to the Centers for Medicare and Medicaid Services.
CMS funds for the program are set to run out by the end of this year, though Congress could vote to extend it for another two years.
In the meantime, many hospitals have been reluctant to invest resources in it, especially if the funding is uncertain. Hospitals bill CMS directly for Hospital at Home patients on Medicare and Medicaid.
"For many hospitals, it seems like it might not be worth it," said Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association.
Some private insurers have signed on, but Atrium Health's Hole said that many of the biggest commercial payers are waiting to see if the federal government continues to fund the program.
While patients languish in ER hallways, waiting for a hospital bed, the federal government has done little else to help.
The Department of Health and Human Services has promised to set up a roundtable within the next six months to "identify actionable next steps and novel opportunities to chart a public-private strategy to address ED crowding and boarding," HHS Secretary Xavier Becerra wrote in a letter in December to the American College of Physicians.
CMS is scheduled to present national Hospital at Home data to Congress later this year.
"Our hope is that in the final quarter of 2024, we can actually introduce a bill that will become permanent," Hole said. "I'm anxious because we're running out of time."
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The wait times in the ER are ridiculous and the insurance is charged for it as well. I personally know of someone who had a blood clot in his leg and was assigned to a cot that was in the hallway of the ER. That I am told is an improvement. He was treated after 7 hours and released.
Way back in my paramedic days, decades ago, we had the same problems. Useless calls at 4 AM!
Non-emergency transport cases that clogged up ambulances and ERs seriously pissed us off.
Some gomer who would call 911 for yet another anxiety attack or a three suture laceration seriously put other lives at risk.
I miss saving lives and delivering babies.
Don't miss fools who expect others to save them from themselves.
It's an issue in all stages of medical care. Rehab facilities here are full. My assistant's aunt fell and broke her pelvis over the weekend. She really only needs rehab, not surgery, but all of the inpatient rehab centers are full, so she's stuck at the hospital. Her husband's health is such that he can't care for her at home, so she can't be released yet. At least there are physical therapists in the hospital to start her rehab, but it's not really the best place for her to do that, and it's using hospital resources that would likely better be allocated toward sicker patients.
ER wait times here are hit-and-miss, but we are fortunate to have several good urgent cares for less serious issues that arise over the weekend or in the evenings, so that takes the strain off the ERs.
Near me there is a community health facility. It has urgent care and lists 6 RN's and 1 Doctor. That one doctor happens to be my doctor. I asked him why they had all those RNs. He told me it is a widespread problem. He told me that for many people those RNs were their primary care physician. I'm guessing that the millions entering the country has something to do with it considering that every staffer at the facility also speaks Spanish.
My cousin is the head of Emergency Medicine for a very large group and he says it has nothing to do with migrants, but rather the shortage of staff due to really long hours and not great pay.
Another race card well played.
How about the fact that our own aging population is overwhelming the system?
Do you think "they" are going to build new hospitals and staff them knowing that in 25 to 50 years they won't be needed?
Who is going to pay for all of the baby boomers entering their retirement years?
Retired from being a paramedic due to 48 hour shifts, low pay and serious burnout.
People, banks, governments theat buy US Federal Bonds.
Not to mention, many healthcare providers are themselves immigrants. My family doctor when I was growing up was Filipino, and his son, born in the Philippines, took over the practice when he retired. I had a colonoscopy a few months ago, done by an immigrant from the Middle East (Jordan, I believe). My sister used to work for a gastroenterologist from Iraq. His brother is a dentist. My ophthalmologist is Russian. A survey of staff doctors in our local health system shows varying shades of brown skin and definitely non-European names.
My dental school instructors were also a diverse bunch - Indian, Greek, German, Korean, Turkish.
Maybe we will get lucky and find a significant number of health care providers in the several million asylum seekers now here from El Salvador, Guatemala, Honduras, Mexico, and Venezuela.
I'm sure that part is true.
Staff is underpaid and nurses have been underpaid. It wasn't that long ago that we were graduating more doctors than we needed.
You mean all illegal migrants are Hispanic?
I'm not sure who is playing the race card there.
It was you that said staffers would need to speak Spanish...
Shhhh.... no one is supposed to know.
How the f is that playing the race card?
Back in my paramedic days learned a few words of Spanish. Enough to ask "where does it hurt?"
And it was directed to somebody else. Did she ask you to respond?
You mean legal immigrants.
As there is not a no-contact restriction between me and Split P, there is no reason for him to avoid responding to me, and there is certainly no reason for you to question him for doing so. This is a discussion site, after all. Civil discussion is why we're here.
But there is a reason why he shouldn't be answering questions directed at you.
Maybe. Maybe they were Dreamers. Maybe they came here illegally, or were brought here illegally, got educations, and have been taking care of patients. Maybe you've been cared for by an illegal immigrant, and didn't know it.
Maybe you've been cared for by somebody whose immigration status is in legal limbo. Maybe you've been cared for by somebody who was educated here, but who will be deported, with all of their years of education and experience, in a few months.
"You don't want him to" isn't really a valid reason, Vic. I made a comment, and SP responded. It is beyond unreasonable for you to be upset by that.
Maybe you can police that meta concern on your own articles first...
[deleted]
There's also the fact that no questions were directed at me for you to have answered. I started a thread, Vic made a comment, and Perrie responded. I replied to Perrie, and you replied to me. No questions directed at me for you to have answered. Not that there's anything wrong with that, on a public forum.
That would be a good thing since Spanish is the second most spoken language in the US and fourth in the world. It also shows that not all immigrants are rapists, drug dealers, and uneducated.
Admitted Hispanics now outnumber admitted white people in Texas, roughly 40% to 38%
Blended families make the numbers questionable. My brides law firm was populated by white women with Hispanic last names and my neighbors with thick Spanish accents have Anglo names.
If you want to compete for customers in Texas you advertise that you speak Spanish fluently.
The same with Florida.
Florida was originally a Spanish territory.
Cali, Texas and what now is New Mexico, Arizona, Nevada and Utah including parts of Wyoming and Colorado
were all part of Mexico/Spanish colonialism.
No wonder there's so much Spanish here /s
Having lived in Florida, Cali, Nevada, Texas and relatives in AZ and NM and speaking Spanish I can vouch that all of those states if you want to do business best appeal to both English and Spanish speakers. And many of them are scientists, engineers, lawyers, doctors, and professionals in many different fields. Damn, that is shocking for some.
"Some" move to the border and are shocked and offended when they see brown people going back and forth across the border!
Just like they have been doing forever...
So we went to visit clients in El Paso and I said something about Eagle Pass and they said "lets go"
"Its a media circus with nothing much to look at" That day there two dozen immigrants detained in the park
surrounded by 60 House members and dozens of journalists and BP agents.
So we go to lunch and the next several tables were "Mom's for Liberty" that came to the border in a bus to help
at the border and most were sorely disappointed
because there were no immigrants to catch
and there are some very, very nice areas of El Paso especially the west side along the Sunland Park Mall.
They seemed to think they were coming to some sort of shit hole with homeless people everywhere.
My friends told them that unless you live on the river/ border
life there is pretty quiet much like every other day in Texas.
If you are still there try L & J Cafe by the old grave yard. It’s almost 100 years old and great food and friendly service.
If you are staying on the West end of town, The State Line has good brisket and beef ribs. There is better but it pretty good there and maybe near by.
Next trip. Our very good friend took a job at a High School in the NM side past Fort Bliss.
Loves the West Side.
Yes. It's all areas. Not enough beds, not enough nurses and definitely not enough rural facilities for people to get care. My father-in-law waited at the ER yesterday for 2 1/2 hours without being seen so he went home. A couple of years ago my mother spent a week in the ER because there were not enough nurses in the hospital to move her to a room. She nearly died from pneumonia and they had her pain meds dialed way too high.
Yes. My sister is a travel PA. There is a huge backlog of patients at the clinic where she works waiting for colonoscopies. The holdup is a lack of anesthesiologists. If you're willing to have your colonoscopy done while you're wide awake, you're golden. If you'd rather be asleep, and who wouldn't, you're out of luck.
I think that they gave me a date rape drug, I apparently wasn’t completely out of it and would comply with the doctor’s instructions but had no memory of the event when it was over.
My next BIG decision apparently.
That is par for the course, it's conscious sedation. They can communicate with you and ask you to move etc
but you are unaware of pain or discomfort.
The other choices are a deep sleep, good for you, bad for them
or being awake and watching the procedure on your own monitor.
Yes, I'm one year out from my next one and will ask for the same sedation.
After one of my knee surgeries a nurse came in to give me a backrub.
I couldn't roll over onto my back so she gave me a front massage.
We both had orgasms and I never even saw her face (to my knowledge).
wide awake? uh...no
Me, neither. No way.
Just another example of the foreseeable problems that are caused by the border invasion. On top of citizens having limited means and resources, the homeless, and the growing numbers of drunks and addicts, here comes thousands of unvetted and uninsured people and kids with a plethora of problems that saturate a (usually) urban area. They have no primary care physician, so an ER is really the only other option, and the hospital is legally required to offer care whether the patient can pay or not.
The majority of these patients can be successfully treated by PA's and FNP's. I've never gone to Denver Health, so I have no idea of the situation there, going instead to a large medical campus on the west side of the metro area. I have no idea how to solve this problem, and government seems to be a large part of the cause instead of being a part of the solution.
I refer you to my comment here:
The article actually explains what is going on.