Bed shortages bottle up emergency departments

The practice has become so common in hospital emergency departments across the country that a term has been coined for it: boarding.

Patients arrive at the ER, are diagnosed and need admission. But instead of being sent on to the intensive care unit, the psychiatric ward or just a regular hospital bed, they get stuck. They can wait for hours, even days, in emergency departments before getting to a hospital bed.

"I have patients who ask me, 'Why won't you let me upstairs?'" said Dr. Francis Counselman, who practices at Sentara Norfolk General Hospital and is chairman of the emergency medicine department at Eastern Virginia Medical School." 'There are no beds to put you in.'"

The problem stems from a lack of inpatient beds and the nurses to staff those beds, but patients pay the price, according to several studies. Bottlenecks in the emergency room drive up mortality rates and health care costs. A study released this week found that elderly patients who are boarded in ERs are more likely to need long-term care when they are discharged from the hospital.

"Inpatient bed capacity needs to be more closely looked at," said Elaine Griffiths, vice president for patient care services and chief nursing officer at Chesapeake Regional Medical Center. "That's a phenomenon I think we need to focus on as a country."

Counselman called it a "national problem,.

"We need more nurses. That's critical," he said. "It's not just the beds; you need a nurse to staff those beds."

The problem is especially critical for specialized beds, such as those in intensive care units or psychiatric wards.

At Norfolk General, patients can wait a couple of days in an emergency department for a psychiatric ward bed, Counselman said. Such waits have become so common that a psychiatrist now includes the ER during rounds to help treat psychiatric patients.

Boarding also bogs down emergency departments, delaying treatment for new patients. Stable patients may await admission on beds in the hallways, but critically ill patients who need to be admitted to an intensive care unit need constant monitoring in a treatment room.

"You haven't just lost the bed; now, the nurse is really tied up doing ICU medicine" in the emergency department, Counselman said.

Emergency medical care is intended to provide treatment that will either enable patients to go home or determine that they need to be admitted to the hospital for care.

Delays in getting that care can lead to higher mortality rates, according to a study of more than 50,000 patients who were admitted to intensive care units from emergency rooms.

Published last June in the journal Critical Care Medicine, the study found that critically ill patients who had to wait six hours or more to be admitted had an in-hospital mortality rate of 17.4 percent versus 12.9 percent for patients who didn't have such long waits. The study also found that the patients in the delayed group stayed in the hospital an average of one day longer.

A University of Rochester School of Medicine study of 277 elderly patients released this week found that those who had long waits for hospital beds faced a more difficult long-term recovery. Of those who had to wait more than six hours to be admitted, 18 percent were discharged to a nursing home, while only 4 percent of those with shorter waits needed such longer term care.

At Chesapeake Regional Medical Center, the problem is not having enough beds, Griffiths said.

In the past couple of months, the hospital's inpatient-bed occupancy rate has been "right up close to 100 percent," she said.

A comfortably full occupancy rate for a hospital is considered to be around 80 percent.

In July, Chesapeake Regional will begin an $8.4 million expansion and renovation that will double the size of its emergency department - the area's busiest, averaging more than 60,000 visits a year. The ER will also be designed so the space can be used more efficiently, Griffiths said. That will help, she said, but it won't solve the inpatient-bed problem.

For years, some health industry experts have been predicting that there will be less need for inpatient beds because of rising outpatient surgeries.

"I don't think they really looked at the demographics," Griffiths said.

In the next couple of decades, the health care system is looking at an influx of aging baby boomers. Older people are more likely to have multiple conditions that preclude outpatient treatment.

Only a few years ago, "we never held patients more than a couple of hours," Counselman said. "Now, it's almost hard to remember those times. It's every day now."

Reuters Health news service contributed to this report.

Nancy Young, (757) 446-2947, nancy.young@pilotonline.com