“Far from the madding crowd” 

Just last week, I met Ms. K on the inpatient medicine wards. She’d been through quite an ordeal. She’d been diagnosed with an exceptionally large gluteal and hip region abscess and after assessments by multiple consultants including ER doctors, general surgeons, orthopedic surgeons, hospitalists, ID consultants, and interventional radiologists, she was finally getting some relief after having a drain placed in the abscess and being on multiple IV antibiotics. She kept up a brave face and told me that after four days, she finally managed to get a couple of hours of sleep. “This is much better compared to the waiting and boarding in the ER,” she mentioned. In fact, she’d first gone to a different ER in the city, waited for six or seven hours, and was then sent home with Tylenol for hip pain. She then came to our ER as her pain worsened and again waited hours before she was seen and then additional hours waiting for a hospital bed to open. This extremely tolerant patient had only words of praise for the ER providers and staff and told me she understood. She’d undergone another similar experience about eight months prior when her Crohn’s disease had flared up. 

This narrative of endless hours of boarding in the ER is sadly commonplace across our country. As plainly stated by the Institute of Medicine a few years ago, our emergency departments are “at breaking point.” It’s well recognized that every hour of extra boarding worsens patient mortality. The millions of hours spent by patients boarding in the ERs leads to extraordinary delays in timely care, unsafe conditions, diagnostic errors, higher costs, and takes a toll on ER providers and staff. Not to mention the ordeal that patients must go through when what they need most is a comforting and healing place. 

While the situation is complex and needs federal and state governments to act together to provide long-term solutions, there are some things every non-ER clinician can do to help decompress our constantly overflowing ERs. 

1. Think locally: what can we do to get inpatients who are ready to be discharged quickly? Reorganize rounding to see potential discharge-ready patients first. Have daily multi-disciplinary rounds focused on advancing care especially when barriers are encountered. Set up patients for discharge by the evening prior including any ambulance rides for skilled nursing facilities.

2. Consider having a “triage” role in the hospital which can oversee all patients awaiting inpatient beds and assign patients quickly when beds open. This can likely be done by algorithms/AI based on patients’ vital signs, possible diagnosis, and inpatient needs like telemetry, isolation, etc.

3. Harness the power of the electronic medical record to determine bottlenecks based on time stamps—like late discharge orders, late nursing instructions, waiting for transportation or delayed room turn around, or waiting for formal admission orders—that is contributing to boarding. Engage stakeholders to improve efficiency in each area. 

4. Counsel patients and prepare them for both the hospitalization process and discharge planning. Not all patients will feel 100% better before they leave the hospital safely. Some of the recovery is completed at home or in rehabilitation. This expectation should be set up in advance so that patients don’t feel surprised or let down. Constant patient engagement and education is key.

5. Engage providers and staff and invest in their wellness. Burnout is a frequent occurrence and employee turnover only slows things down more. Experienced staff will provide the best local solutions and role modelling that is much needed for efficient care.

I explained to Ms. K every day about her progress with the treatments. She needed several weeks IV antibiotics post-discharge. She preferred to have it done at home, but for some reason there was a 10-day delay before home care could be set up based on her insurance. She had an accepting skilled nursing facility and she herself changed her mind and decided to try the facility. Her reasoning was simple—“Somebody else can use this hospital bed instead of waiting for days.” She was giving up her own needs for the needs of the community. I was in awe.  

In summary, prolonged ER boarding occurs every day and is dangerous. Everyone in the hospital can play a role in reducing its impact on our patients and our community.  

With tremendous gratitude to Ms. K for showing flexibility and kindness. 

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.