Overcrowding in emergency departments is reaching crisis levels, which threatens patient safety

In two new studies, Yale researchers have documented widespread and rising rates of overcrowding in America’s emergency rooms, a crisis that threatens patient safety and access to care.

For research, the researchers studied, respectively, the progression over the last years of two indicators of ED function and hospital capacity: length of stay in the hospital — or how long patients stay in the intensive care unit after doctors decide they need to be admitted — and how often patients leave the intensive care unit before receiving care.

Their findings, they say, help characterize the larger problems underlying emergency room overcrowding. And they show that the problem has worsened during the COVID-19 pandemic. Their methods also provide a more timely assessment of these key metrics, which have historically been difficult to obtain.

“It’s not a problem of treating the reaction,” said Arjun Venkatesh, an assistant professor of emergency medicine at Yale School of Medicine and an author of the study. “These are indicators of overstretched resources and symptoms of deeper problems in the health care system.”

Both studies were published on September 30 at JAMA Open Network.

It was in the 1980s that ED overcrowding became an issue of national concern. The problem has only worsened in recent decades, with negative consequences for patients and hospital staff are similar. Studies have shown that emergency room overcrowding correlates with discomfort, reduced privacy, treatment delays, and a higher risk of long-term morbidity and death. Emergency room overcrowding also leads to increased violence against staff, higher turnover of clinicians and nurses, and high levels of burnout. A recent study found that in 2021, nearly 63% of American physicians surveyed will experience burnout.

In one of the new studies, researchers found that the length of stay in the hospital, or the time the patients stayed in the emergency department after clinicians determined they needed to be admitted were associated with hospital occupancy rates or the percentage of inpatient beds occupied. The Joint Commission, an independent national health care accrediting body, recommended that boarding times not exceed four hours.

For the study, Yale researchers evaluated these measures in US hospitals during the COVID-19 pandemic from January 2020 to December 2021. They found that when occupancy exceeded 85%, boarding times exceeded this four-hour standard. In fact, under these conditions, the average boarding time in the ED was 6.58 hours. Boarding times also deteriorated during this time period, outpacing occupancy rates.

This relationship makes sense, says Alexander Jahnke, the study’s lead author, because when occupancy is high, there are few beds available to move patients out of the emergency department. And as the capacity decreases, the waiting time increases.

“Hospitals need to have the flexibility to accommodate emergency patients who need to be admitted,” said Jahnke, who conducted the study as a fellow at Yale School of Medicine and is now at the University of Michigan. “And that ability doesn’t exist in many places.” This means that patients stay in the emergency department until space opens up at their destination, and emergency beds remain occupied, limiting the number of new patients.”

The latter influence can affect the waiting time for an ambulance. And if they are long, patients are more likely to leave for evaluation. In a second study, researchers assessed the frequency with which patients in US hospitals decide to leave an emergency room before being seen by a clinician.

From January 2017 to December 2021, the average rate of patients left without a follow-up nearly doubled from 1.1% to 2.1%. In the worst-performing hospitals, those rates were as high as 10% by the end of 2021, a figure Jahnke called “amazing.”

“It’s a measure of access to health care,” he said. “If you have to wait hours and hours to be seen in the ED, that’s not the access to care that we require by law in [the Emergency Medical Treatment and Active Labor Act, or EMTALA].” (Enacted in 1986, EMTALA requires universal provision of emergency medical care by hospitals that accept Medicare payments.)

The researchers say the findings provide a snapshot of the current state of EDs in the United States and provide important data that is usually difficult to obtain in a timely manner. Although hospitals are required to report certain measures annually, those data are often not released for another two or three years, making them irrelevant, Jahnke said.

” health care system it’s a living, breathing organism, and it’s like we took its vitals once three years ago, and that’s how we do public policy,” he said. “You and I need to know if the emergency system is capable, where we live will be affected by, say, a family member having a heart attack or stroke. This is a problem that affects public health.”

Researchers want people outside the ED community to recognize this population-level effect and the consequences of ED crowding.

“We hope that our findings will begin to draw attention and accountability to the human toll of the emergency room crisis,” said Ted Melnick, an associate professor of emergency medicine at Yale School of Medicine and an author of the study.

For both studies, the researchers collected data from a major provider of electronic health records, an approach that is particularly useful when other national or local data are not available.

“Future partnerships with electronic health record providers may continue to shed light on such crises,” Melnyk said.