Yale School of Medicine’s Emergency Room Physician, Dr. Arjun Venkatesh, MD talks about overcrowding in the emergency room and how to change that.
Interview conducted by Ivanhoe Broadcast News in 2022.
So we were just talking about the fact that emergency room overcrowding is not anything that’s new. Can you give me some perspective?
VENKATESH: Yeah. Going back to when I was in medical school, we would talk about crowded emergency departments the boarding of patients waiting for a bed upstairs. And so this problem has been growing for decades. What’s happened in the last few years though it’s really accelerated many forces and things were already in play before COVID. Hospitals have been closing. The number of hospital beds in the country has been fewer. At the same time, people are living older, longer, and sicker, more cancers, more other diagnoses. And so the need for emergency care and hospital care has never been as great with as little supply of that care to deliver.
What happened with the emergency rooms during COVID?
VENKATESH: I say often that COVID turned the fireplace into a forest fire when it comes to crowding in our emergency departments. We knew there was a problem beforehand. Hospitals were trying to manage it in a variety of different ways. What COVID did though, was that it created a massive shortage of healthcare workers around the country. Almost anywhere you go in this country, just as we have shortages of people to work at any assembly plant or any service sign job. The same is also true in health care. Healthcare workers are tired from the pandemic for many reasons they are leaving the workforce early, they’re picking up less over time. And so we have fewer nurses, fewer ultrasound texts, fewer doctors, you name it. And that makes it really hard for hospitals to function and therefore emergency departments to function.
Because my question would be, well, COVID has slowed a bit. So are things going back to normal but not from what you said?
VENKATESH: They’re not, this is different, I think than in the past. In the past, we would see waves of hospitals under crisis. There would be a really bad flu season. We’d need a lot of beds for flu patients and we didn’t have enough space for patients with a heart attack or a stroke. But COVID is one of those once-in-a-lifetime, I think changes in the health care system. What we’re now seeing is nursing facilities that aren’t able to run at full capacity or full effectiveness. And so patients in the hospital are waiting for a bed at a nursing home. A bed at a rehab facility, a home health aide to be able to help them take care of themselves after they get discharged. And when the whole system slows down everywhere, that backs up to the hospital and then backs up our ERs.
How long have the waits gone at some of the ERs?
VENKATESH: It was pretty common that in many emergency departments around this country because of a lot of changes they’d been making run operational efficiency you could get seen within minutes. And the idea of waiting beyond 30 minutes in most community years in this country was rarely unheard of. What we’re now seeing is that not only are wait times going up but really concerning is the sickest of patients, those who come to the emergency department are evaluated, they receive diagnostics and treatments and then they need inpatient hospitalization. They need to stay in the hospital or waiting 2, 3, 4 up to 12 and 24 hours for a bed in the hospital. And so what we see is that the boarding times are nearly doubled over the past- over the recent years. And what that’s resulted in is back up in the ER and doubling and tripling in some ERs of the number of patients who end up leaving without ever getting seen. For years we’ve institutionally tried to say, we want to keep hospitals around this country with fewer than two percent of patients that walk out without being seen. And that number had gotten to as low as one percent. What we’re now seeing is many hospitals- majority of hospitals in this country well above that two percent mark and five or 10 percent of hospitals where 10 percent of the patients who come to the emergency department to be seen, one in 10 people who come to the emergency department end up leaving without receiving care because the wait is too long.
But what is the danger when you have these people who are coming to be seen they just give up?
VENKATESH: I think there’s a myth out there that people who come to the ER may have minor problems. They’ve got a runny nose and sore throat, and just wanted to be seen at night or they’ve got an ankle sprain, but that’s no longer the case. We now live in a world where there’s urgent cares, telemedicine, other access everywhere. The patients that come to our emergency departments we know tend to be older. They tend to have many chronic conditions. They tend to come with things like chest pain, abdominal pain, headaches that could be signs of a heart attack, appendicitis, or a stroke. And what we know is if they wait and they leave, the patients who end up leaving are often sicker when they return, they come back with a perforated appendix. They come back with a pneumonia that turns into sepsis. They come back with some mild chest pain that turns into a heart attack. And they’re more likely to be hospitalized when they come back for care.
What are some of the solutions? This is not an easy fix.
VENKATESH: It’s not an easy fix. It’s not an easy problem. And so I think there are many things hospitals have been doing over the past few decades to try to combat this problem. The low-hanging fruit is done. It’s already baked in. People have already tried those things. We’re now at a spot where we need really fundamental redesign of how we deliver health care. And we need to shore up these important anchor institutions and structures of health care in our communities. So we need a massive infusion of effort to staff up our nursing homes. If we can’t get our nursing facilities up and running again, or we can’t provide better hospital services at home through new hospital and home models or telemedicine models if we can’t change how we deliver care so that the same number of people can care for more people safely we’re not going to be able to get out of this. I think it’d be a mistake to say that we’re going to wait for the nursing schools and medical schools to graduate enough grads. We have such shortages across every healthcare worker. It would take decades to fix this by just training more people.
How do you do that? How do you do that stuff without waiting for the next generation or the next class of graduates?
VENKATESH: I think some of the things that are going to have to be innovative uses of technology. We have a lot of waste and inefficiency in health care. Everybody knows that. We’ve got things where we have high skilled health care workers, nurses doing things such as utilization review, reviewing charts to fight with the insurance companies about how much that- visits you get paid for. We have to rethink healthcare delivery. We have to figure out how to get people back to the bedside who have the training and the skills to do it and maybe we start using artificial intelligence, computer technologies, other tools that we have to do the back-office work so that those people can be taking care of patients and be more effective at doing that.
I know this paper was just published at the end of September. Which journal?
VENKATESH: So it was in JAMA Network Open. We had two papers that came out at the same time. One was looking at these phenomena of ED boarding. So people who are waiting to get a bed upstairs and the other looking at the phenomena of people who leave without getting seen in the emergency department.
Can both along the same vein now?
VENKATESH: Both very related. You can’t have one without the other. I worry a lot more about those who leave without being seen because I think it’s almost forgotten what it’s like to not have access to an ER in your community. Back in the ’70s and ’80s, people and many communities around North America would go to the emergency department seeking care and could often get refused care. If they couldn’t pay for it if their insurance wasn’t good enough, they’d get redirected to another hospital. There was no guarantee that you had access to emergency care on one of the worst days of your life. A law was passed called EMTALA that guaranteed everybody in this nation access to an emergency department visit at a time of emergency. And what’s happened defacto is while that law is still on the books, and fortunately, there’s very few violations of that law as emergency departments have improved and hospitals improved around the country. Defacto when people come and wait so long that they leave, they don’t have access to that visit that that law intentionally intended. And so I think what we have to also think about, and this is for policymakers out there, is that that law was passed, but there was never any funding behind it. It was a requirement that everybody be seen, but there was no payment to ensure that there’ll be an emergency department open 24/7 in your community. I think funding that mandate now really does show an important need and would fill this gap.
Is there anything that I didn’t ask you that you do want people to know?
VENKATESH: I think one thing I want people to know is that you may live in a community where COVID rates are fairly low or COVID hospitalizations are fairly low, or you think that this is a COVID problem. And our research showed that that was not the case. What we find is even now at a time when COVID hospitalizations are declining, COVID deaths are declining. We’re headed in the right direction in general on the pandemic in many communities and even in times during the pandemic, when some places were quiet with COVID, while other places had mass spikes and hospitalizations it was completely unrelated to this problem. This is a more than COVID problem. This is with us for the coming years, even as we get out of the pandemic. And it really requires us rethinking how we deliver health care in this country and not just hoping that when COVID goes away, this will go away.
END OF INTERVIEW
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