Emergency rooms are not okay
yourlocalepidemiologist.substack.com
yourlocalepidemiologist.substack.com
> The primary problem is not the number of patients coming to the ER. It’s the lack of open beds upstairs.
She goes on to explain that most of the problem is that hospitals keep their beds full so as to maximize profits, with a variety of reasons ranging from nursing home shortages to hospitals' tendency to prioritize elective surgeries (these make more money).
In fact, this entire article is very bad. The author asserts a problem, but provides no actual data to support the assertion, other than linking to some tweets of other people's opinions (edit: I shouldn't have said tweets; these are mostly links to pop journalism and editorials). Here's a paper quantifying the boarding problem in hospitals in the US, during the worst part of the pandemic:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9526134/
to wit:
> Occupancy rates and boarding time had a threshold association: when occupancy exceeded 85%, boarding exceeded The Joint Commission 4-hour standard for 88.9% of hospital-months (Figure 1). In those hospital-months, median ED boarding time was 6.58 hours compared with 2.42 hours in other hospital-months (P < .001). Across all hospitals, the median ED boarding time was 2.00 hours (5th-95th percentile, 0.93-7.88 hours) in January 2020, 1.58 hours (5th-95th percentile, 0.90-3.51 hours) in April 2020, and 3.42 hours in December 2021 (5th-95th percentile, 1.27-9.14 hours).
The current objective in hospital medicine is to get the patient home as soon as possible. There's a lot of good reasons for that, hosiptals are disease cesspools. Basically if you don't need intensive care they want to send you home.
But, it doesn't have anything directly to do with the so-called "boarding problem", which is what this article is about. That's mostly about the for-profit nature of our health care system, which is doing exactly what one would expect (optimizing profits).
Guess why?
Because new hospitals need a Certificate of Need to be approved for construction.
What's that? It's a process by which -other hospitals in the area- get to say whether a new facility should be built. In many cases, this means a fine tuning of things to make sure you maintain available beds across all hospitals just short of the actual need (because if your facility is going to absorb the need, and leave others with empty beds, then you ain't getting your certificate).
This process was lobbied for by the hospitals themselves.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6754202/
https://www.jointcommission.org/-/media/tjc/newsletters/quic...
Here's the hosts linked to by the article:
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[ "www.acep.org", 4 ]
[ "substackcdn.com", 3 ]
[ "link.springer.com", 2 ]
[ "onlinelibrary.wiley.com", 1 ]
[ "papers.ssrn.com", 1 ]
[ "catalyst.nejm.org", 3 ]
[ "www.washingtonpost.com", 1 ]
[ "mmshub.cms.gov", 2 ]
[ "yalesurvey.ca1.qualtrics.com", 2 ]
[ "youcanknowthings.com", 1 ]
> Wait times and staffing shortages are worse today than at any point during the pandemic in many communities. The resulting bottlenecks are overwhelming hospitals, causing dangerous delays, and putting lives at risk. Emergency care teams are strained to their limits. Demand for emergency care and services shows no signs of slowing as we head straight toward this winter’s “triple threat” of flu, COVID-19, and pediatric respiratory illnesses like RSV that are filling emergency departments. The influx of patients only piles more stress onto the shoulders of emergency physicians, who are doing all they can to treat anyone who needs them.
Aside from leaning heavily on emotional wording ("strained to their limits", "doing all they can"), these kinds of claims are meaningless without data. The rest of the piece is no better -- it's just anecdote after anecdote, written in newspaper style.
The second link is a poll of patients. That's data of some kind, I suppose, but it's not what you'd use to support the claim. That's the entirety of the evidence advanced to prove the fundamental claim that emergency rooms are "overwhelmed".
Point being: I looked at the links before I wrote what I wrote. The "evidence" being used here is mostly opinions, surveys and editorials. It's a classic example of "evidence laundering", wherein someone links to pop articles on reputable-sounding domains to make bald assertions sound like rigorous research.
I said "tweets" because I thought I saw a link to X in there, but I think I was wrong about that. Mea culpa.
The ED in the larger hospital near me where we take most of our patients (a Level 2 Trauma Center which, for the benefit of simplification is essentially a Level 1, without teaching facilities attached) about 8 years ago (say 2-3 before COVID) had 4 "pods", A-D, A and B on one side, registration, waiting, intake, in the middle, and C and D on the other (they formed something of a horseshoe around the intake area). Each pod had 10 rooms (they don't have ward style multiple patients to a room).
It used to be that C and D pods were "peak hours only", and after 3 or 4pm, there were no patients, and the lights were down.
Then things changed. C and D pods run 24/7 now.
And there are 24 "hallway beds" which are typically lower acuity patients literally on gurneys in the halls, one in front of each room.
Then the psych holding area (5 secured rooms) started overflowing.
Patients are now given gowns and scrubs based on their needs. A shocking number of the hallway beds are brown scrubs, which indicates mental health, often with a hold in place (i.e. they are not "free to leave", until evaluation and treatment plan has been determined, as a threat to themselves or others).
Oftentimes this means finding an inpatient bed elsewhere.
I have, tragically, watched frequent fliers with severe mental illness wait multiple days on a hallway bed. Nothing to read, watch, look at. No rest. No pause from the chaos. At least in a room, you can have a curtain drawn, lights dimmed. Not in the hallway. 24/7 we're wheeling patients by you as EMS, conversations at nursing stations. For me, perfectly "sane", that would drive me to the brink, to someone already in crisis ... The only "solution" that is compatible with that environment is sedation. (To be clear, it is not a solution, just the only one compatible then and there).
> hospitals' tendency to prioritize elective surgeries (these make more money).
At least this hospital, and a couple of others I know in the near region, hospitals have expanded their outpatient surgery and elective surgery, already in its own building, to include inpatient, too, so those patients are not taking up room for admissions out of the ED.
The person doing the arguing will pick and choose their examples to fit their preferred narratives.
I avoid the ER unless I think I am putting my life at risk by not going. I cut my finger open earlier this year, it probably could have used stitches but I was not going to subject myself to the ER experience for that. I taped it up, kept it clean, and it healed. There's a scar, but I'm not a hand model.
Wellbeing improves productivity
Someone's going to stand around when there's an imbalance between demand and labor supply. At our local grocery store, they overhire high school kids to stand around waiting to check people out. I've never waited in line for more than 3 minutes there. If they cut costs by firing the extra labor, I'd have to stand around and wait for the "optimized" labor force to attend to me.
The incentives of hospitals are much more complex than those of grocery stores, because of how different their business is. One of their major customers, for all patients, is the government -- which rewards some things and not others. Unlike the grocery store, then, the hospitals have to be quite attentive not only to the experience of people coming the door but the metagame of quality measures -- what the government thinks the experience of those people is. The article hints at a reasonable solution, which is for the government to include surplus capacity as part of their incentive structure.
From a patient care perspective you overprovision so that pretty much any surge doesn't exceed capacity. But note that the cost to the hospital is pretty much based on what they provision for, not what they actually do. You're not paying the hospital the big bucks for actually doing, you're paying for the capacity to do it.
From a profit perspective you overprovision only to the point where the marginal value drops to zero, a point far below the peak of a surge. Unless mandated otherwise no business provisions to the biggest surges.
I think public is worse than private in this regard, it's a lot easier to change the definition of acceptable than it is to fund what really should be done.
I am really hoping more people will be aware of the time they’re wasting and at least understand there’s a reason things are slow. Understaffing is a deliberate choice, and time is an extra tax that people apparently don’t consider. If you price your time at zero, the store will too.
In other words you can have a system which prioritizes profit, or you can have a system that prioritizes care. But you can't prioritize both.
There's always some kind of rationing of the limited resource. There it's based in large part on you or your insurance's ability to pay. Here it's based on how much the government/taxpayer is willing to shell out.
If one party gets elected on the promise of lower taxes and lower spending, then the people cannot complain when there is lower spending. If the spending gets too low, and health, education, housing, and infrastructure start creaking, well, who's to blame for that?
Polite? I cannot day
Obviously true, but
What we need is something that looks at that efficiency-care-quality tradeoff curve and finds something like the markowitz efficient frontier. Now.. that hospitals operate at such efficiency ought to be a consequent of capitalistic competition even in a for-profit context. The american health system is so crooked and bureaucratic and overpriced, perhaps the most we can do is demand our hospitals be non-profits. Many "non-profit" hospitals seemingly have megabooms in growth, which makes me wonder where the money is coming from to fund the growth, if not profit.
Equally it does not mean unlimited resources. Clearly we live in a real world, and Healthcare will always be resource constrained to some degree.
Those who allocate resources still decide priorities, and clearly health becomes balanced with education, justice, military and so on.
So perhaps in deciding between for-profit and non-profit it's really a decision between who gets to allocate the resources. Do we prefer people out to squeeze every last dime out of you, or people looking to get re-elected by their constituents?
Quality of life while undergoing treatment is also entirely non-existent, trust me, you to not want to be "immortal" if it required indefinite ECMO. Unless you enjoy living in hospitals I guess.
Remember that hospitals and hospital owners lobbied the Nixon administration heavily to get this process put into law, and it becomes a bit clearer.
Not to get political, but when a service goes from being a luxury to being considered a human right, our tolerance for failure changes immediately. Anyone who works in reliability knows that the budget for “will never fail” is exponentially higher than “almost never fails”.
As we transmute more services to “fundamental right”, we need to expect costs to grow non-linearly, regardless of who is paying. None of this is a bad thing, we just need to be building freakin’ massive hospital buildings!
The scale out cost for hospitals are in the order of billions and decades to become available.
The US needs significantly more diversionary, urgent care resources - a cut or fracture below a certain threshold does not need to be in the same emergency room as a stab victim or crush victim.
Going back further, preventative care absolutely needs to be in place so chronic illnesses do not progress to the point of emergency.
The Australian model is simple enough: for medications, for the most common treatments, these are on a pharmaceuticals benefits list. The government guarantees the price is kept low, even if the manufacturer is charging ridiculous amounts. This works, because paying $600 extra a month for someone's pills from taxes saves $1200+ of them not rocking up to hospital on death's door 12 times a year.
The concept of a fundamental right here depends on a morality that says everyone has a right to live, and that society should help make that possible, probably partially through taxes.
If your morality is different, your opinion of whether the above are fundamental rights, might also be different.
I personally agree with both points: I believe "pretty good healthcare" is a fundamental right. That is to say, it should be limited only by factors humans can't control (e.g the lead time for training new people), and otherwise be "best effort" given that constraint.
Strong disagree. Let's think back 100, 200 years. A huge percentage of the population built their own shelter and grew their own food. The idea that the government ought to be required to supply these to everyone (as a "fundamental right") is very much a late 20th century concept.
I agree that the government stepping in and trying to feed and house all its citizens is a noble goal - but this leads to a discussion around some minimum amount of effort and personal responsibility, or whether you want to live in a society where nothing is ever expected of the people, that it's OK for healthy, capable citizens to simply "opt-out" of work or productive pursuits, knowing the government is responsible for providing food, clothes and housing, seeing that it's a "fundamental right."
The same could be said of medical care. I don't see how that affects morality today.
> The idea that the government ought to be required to supply these to everyone (as a "fundamental right") is very much a late 20th century concept.
I still don't see what history has to do with anything here. Is it a "late 20th century concept"? Maybe, maybe not, but that doesn't affect whether something is morally a fundamental right.
It sounds like you fit into the "different morality" bucket I mentioned above, so we should expect you to have differing opinions on what rights are fundamental (and that's okay). And if you have differing opinions on what rights are fundamental, than we should expect you to have differing opinions on what the government should do to guarantee them. Which you appear to (and that's okay).
There are a bunch of things where I'd rather wait 8-24h at home, even in pain, than go to an overloaded emergency room.
I think it would he interesting to compare teal estate prices and rent with ER overcrowding. My guess is few of the surplus patients own nice homes.
Why aren't there facilities out there that just specialize in the elective surgeries and don't have ERs and other things that are money-losers?
Seems like you could provide all the money-making services without the money-losing ones.
There definitely are. But I wonder if the main sticking point may be access to an ER in case something goes terribly wrong during surgery. I know that gets used as a bludgeon against abortion providers, but I imagine the same basic regulations apply to any clinic offering surgical services.
The United States is falling apart, and it is no longer capable of solving its own problems. Now, inertia keeps legacy systems functioning, until fascism and/or balkanization a-la USSR takes over.
There it is. The ER, even with its shortcomings, is a better user experience. You have a medical concern, and you get it addressed in a reasonable time— not the weeks or months you need to wait for your primary care or a specialist to be bothered to see you.
Similarly, seeing an EM physician for "what ails you" might check the "got seen in under 24 hours box," but I try to be very up front with my patients that "unless you have a heart attack, a stroke, a car accident, have cut off a body part, etc. you might be getting second or third-rate care from me." I usually try to phrase it as "I didn't get any training in non-emergency problems, and I think you deserve to see a doctor which the right expertise, so I think waiting for that scheduled appointment is worth it, even if it takes a while."
It is hard to help people understand that no matter how bad the alternative is, that doesn't make me any better at dealing with non-emergency conditions.
> Year 4 of a pandemic
- Is a doctor - With a PhD ontop of the medical degree - Who works in an ER setting - and is able to specifically know and understand what the word pandemic means
... In the context of a blog post about ER throughput.
Let me just check for a second and, oh look at that: the author is all of those four points.
COVID infected huge numbers of people, and variants of it continue to reinfect. Long term problems exist in a significant number of people - https://www.nature.com/articles/s41579-022-00846-2
COVID has not magically vanished: https://www.idsociety.org/covid-19-real-time-learning-networ...
It is very much still a pandemic, if for some reason you do not believe that.
Otherwise I have to assume you are rejecting the entire article because you do agree it's still a pandemic, but for some reason can't picture why long term effects of COVID may have a relationship to hospital presentations and complexity of cases.
It's actually a neoliberal disease worsened by a new virus.
/s
2023 provisional data puts Covid at #10 at 50k/yr and this is undoubtedly an undercount as patients that die of a deadly clot due to Covid are likely to not be counted as Covid deaths.