In a pair of September studies, Yale researchers found that emergency department crowding has been reaching crisis levels, compromising patient safety and access to care.
Between the start of 2017 and the end of 2021, the median rate of patients who left the emergency department (ED) without being seen by a clinician had doubled from 1.1 percent to 2.1 percent. Among the worst-performing hospitals, one in ten (10 percent) of ED patients left before a medical evaluation at the end of 2021, compared to 4.4 percent in January 2020, and 4.3 percent at the beginning of 2017.
"It's a measure of access to care," said Alexander Janke, one of the leading researchers for both studies. "If you have to wait hours and hours to be evaluated in the ED, then that's not the access to care that we have required by law in [the Emergency Medical Treatment and Active Labor Act, or EMTALA]."
The act, passed in 1986, requires hospitals that are funded by Medicare and Medicaid to provide universal provision emergency care which may include offering blood tests, imaging, and consultation with specialists to decide whether the patient is presenting with an emergency medical condition.
Similarly, the second study measured boarding time, which is the length of time patients in the ED wait in the hallway for a bed to become available. Between the start of 2020 and the end of 2021, the median ED boarding time increased from 2.00 hours to 3.42 hours. The Joint Commission, an independent national health care accrediting body, has recommended that boarding time not exceed four hours. Boarding is also an indicator of overwhelmed resources and the downstream effect when hospital occupancy exceeds 85 percent to 90 percent.
"This is not an ED management issue," said Arjun Venkatesh, a co-author of the studies. "These are indicators of overwhelmed resources and symptoms of deeper problems in the healthcare system."
The findings also revealed the “failure of the emergency care system to maintain broad access in the context of pandemic demands,” suggesting that current regulatory and financial incentives may prove inadequate in future pandemic waves or disasters. To mitigate these problems hospitals have elected doctor-in-triage or split-flow models, however, researchers suggested that these operational changes are not sufficient to stem the issue of overcrowding in the emergency room.
"We hope our findings begin to draw attention and accountability for the human toll of the ED boarding crisis," said Ted Melnick, one of the coauthors of the new study.
In a 2006 study, having a senior emergency doctor in triage to screen patients and to initiate further workups and treatment was found to shorten ED wait and processing time.
The split-flow model works in a similar way whereby a physician in triage (PIT) briefly evaluates ER arrivals and initiates orders for labs, imaging, and treatment as needed, then determines whether the patient will be managed by the PIT-MD team including a physician assistant, or whether the patient will be transferred to the main ED to be evaluated by the main ED provider. In a 2021 study, there was no difference reported in rates of CT ordering or CT yield in patients seen by a PIT compared to transitional models, meaning that greater efficiency can be achieved without the cost of increased or decreased imaging use.