Second Opinion NPR Podcast: Alex Janke on Emergency Department Boarding

No Room at the Hospital

As I stood in our emergency department, in rooms and hallways around me, more than 100 patients were waiting to be admitted to the hospital. And this happens every day.

And let me be clear: these weren't people waiting to see an emergency doctor. They'd already been evaluated and were sick enough to need hospitalization.

The problem? There was nowhere for them to go.

It's tempting to blame crowded emergency rooms on people showing up with colds and other minor problems. But Dr. Alex Janke, an emergency physician and researcher at the University of Michigan, says that's not what's happening. "ERs are congested with the challenge of moving patients forward in their care from that first step in the emergency department to the steps downstream in their inpatient management."

The real problem is often a traffic jam throughout the health-care system. Hospital beds are full. Patients upstairs may be ready to leave but can't get into a nursing home or rehabilitation facility because they are full. Meanwhile, new patients keep arriving in the ED.

Janke continues: "That practice of keeping patients in the ER while waiting for an available hospital bed upstairs is called boarding, and it is a really important public health problem in many ways."

And boarding isn't simply uncomfortable. It can be dangerous. Research has linked prolonged boarding with delayed treatment, medical errors, and worse outcomes.

Take, for example, a patient with Parkinson's disease who Dr. Janke recently treated. He stabilizes the patient in the emergency department and admits them, expecting the hospital team to take over. But, "if the inpatient team — stretched thin themselves — aren't able to come and do an intake on that patient for eight or 12 hours, that dose is delayed, and that can be a really, really serious problem for someone with bad Parkinson's disease.”

The patient is technically admitted — but still physically sitting in the emergency department, caught between two teams.

Janke's research across 17 health systems examined this vulnerable transition from emergency to inpatient care. Some hospitals did much better than others. Interestingly, hospitals already tracking the transition tended to perform better. Janke says, “You only can make better what you measure." And he's right. We certainly need to measure how long patients are waiting and where care breaks down. But measuring a traffic jam doesn't make it disappear.

We can pressure emergency departments to move patients faster. But that doesn't create another hospital bed, another nurse, or another opening in a nursing home. And pushing patients through one part of the system faster may simply shift the bottleneck elsewhere.

As Americans get older and develop more complicated medical problems, the pressure on hospitals will only grow.

That's why emergency room crowding matters even if you rarely visit an emergency room. Someday you — or someone you love — may arrive with pneumonia, a broken hip, or a stroke, and need that bed.

The crowded emergency department isn't the disease. It's a symptom of an American health-care system running out of room.

– Dr. Michael Wilkes with a Second Opinion