Emergency room medicine and the ethics of boarding patients
Pines: The term boarding "needs to be defined"
The boarding of patients in hospital emergency departments occurs every day across the country and is not atypical, experts suggest. But when a study was published showing that acute coronary patients can be treated in the waiting room of a severely crowded emergency department, Arthur L. Kellerman, MD, MPH, FACEP, of the Rand Corporation in Arlington, VA, decided a line had been crossed.
Kellerman, who also holds a clinical appointment in the department of emergency medicine at Emory University School of Medicine in Atlanta, decided to respond with an editorial published online in September in the Annals of Emergency Medicine titled "Waiting Room Medicine: Has It Really Come to This?"
"It is the [situation], the ethical dilemma, that emergency physicians face every day and every night: 'Doing the best that I can for the patient in front of me. And by doing that, am I enabling a system that ultimately harms far more patients, because we've not drawn the line on inappropriate behavior?'"
With 30 years of experience in the field of emergency medicine, over this time, Kellerman notes that on the one hand, "there have been remarkable developments in treatments, diagnostics, techniques [and] training remarkable scientific and clinical progress in three decades in this very young specialty."
"On the other hand, I've seen the environment in which we practice increasingly compromised, and increasingly eroded, and increasingly dangerous to patients and to health care providers through what I can only conclude is active neglect on the part of managers of the health care system who really don't want to come to grips with the challenges that are facing emergency care in this country," Kellerman explains.
And while there have been amazing innovations in emergency medicine all toward the goal of providing "humane and decent care to patients" the emergency department environment ultimately "has progressively restrained emergency departments from doing what they were designed to do, which is to promptly evaluate, stabilize, admit, or discharge emergency patients."
"So, the real question here is: When is enough, enough? And what will the specialty do about it? But far more importantly, what does our country and our society want to do about it?" Kellerman asks.
Despite what he describes as two decades of "extensive documentation voluminous documentation of the problem, the deteriorating situation, [and] growing evidence that it produces adverse outcomes including death and disability," the typical American "still thinks that if you pick up the phone and dial 911 and you roll into a hospital, you get swift, prompt, and efficient care, and everything will be fine."
"And when that does not happen and there is no assurance that going to a suburban hospital or a private facility with your platinum Blue Cross card will be any better protection than being a poor patient in an inner-city hospital they're shocked, they're outraged, and they blame the doctor and nurse in front of them," Kellerman explains.
Defining "boarding" of patients
Jesse M. Pines, MD, MBA, MSCE, director, Center for Health Care Quality, and associate professor of emergency medicine and health policy at George Washington University in Washington, DC, responded in an e-mail to questions from Medical Ethics Advisor that the answer to the question of should patients be boarded in emergency departments is "certainly no, but boarding needs to be defined."
Boarding, Pines writes, is "the time from the decision to admit (or administrative bed request) to ED departure."
"It would be impossible for the boarding time to be zero in most cases, because there has to be some reasonable time for the hospital to process the bed and transfer the patient to an open, ready room," he writes.
While recommended maximum boarding times range from one hour by some groups to two hours by other groups, Pines maintains, "Keeping patients boarded in the ED long periods of time (i.e., beyond one or two hours) is unethical, particularly if space exists in the hospital for that patient and what is holding them is administrative inefficiency, such as delays in 'accepting' the patient, delays in transport, or delays in cleaning an empty inpatient room."
Pines suggests that when a hospital "does not have sufficient space for an ED patient, it should look to its policies to understand, why, and . . . look to practices that involve reserving beds for only patients [undergoing elective procedures] and allowing the ED patients to fill in any capacity unused by the elective cases."
"This practice is unethical for several reasons," he writes. "The first is that ED boarding is associated with poorer outcomes and higher numbers of medical errors. It is also unethical because boarding is the major cause of ED crowding, which in [and] of itself can be hazardous. As the number of boarders increases, the effective capacity of the ED is reduced, which increases waits, as there are fewer active treatment spaces for the new, undifferentiated cases.
"So, permitting boards is a violation of beneficence, because it is not in the best interest of the patient being boarded, but also not in the best interest of the new, undifferentiated patient in the waiting room. Both can experience negative outcomes from this practice," Pines writes.
Why the delays in admitting?
In Kellerman's editorial, he sets forth three theories on why emergency room crowding persists, despite proof of grim outcomes as a result: economics, ignorance, and acculturation.
First, economics. Kellerman writes, "The Government Accountability Office and the Institute of Medicine have observed that when inpatient beds are scarce (as they frequently are), elective cases almost always get priority for bed placement over emergency admissions."
"Hospital administrators do this because elective admissions can be financially screened in advance, they generally pay higher margins, and accommodating them ensures that the physicians who admit them won't switch their allegiance to a competing hospital. It is far easier and less financial damaging [under the requirements of EMTALA] to divert inbound ambulances," he writes.
Pines writes that the practice whereby hospitals reserve bed space for patients undergoing elective treatments and not for the unexpected admission(s) from the ED "varies from hospital to hospital, but in general hospitals do not reserve rooms for ED patients in advance and they do reserve beds for elective patients."
Boarding occurs, he suggests, when the number of patients who need to be admitted exceeds that hospital's bed capacity.
"Because elective patients have their spots 'reserved' in advance, ED patients are the ones that experience the 'boarding' and are exposed to the potential for negative outcomes," he writes.
"The real ethical question is whether it is unethical to continue to admit elective cases when there is a hazardous situation in the ED. I would argue that this is unethical, but hospitals may resist cancel[ing] elective admissions because these often result in higher payments. In addition, having an elective admission canceled would probably be inconvenient for the elective patient, and the time-sensitivity of their procedure would need to be carefully considered," Pines writes.
Second in Kellerman's reasoning for why this problem exists is ignorance. He writes, "Many hospital administrators approach crowding with the same alacrity Sergeant Schultz (a fictional character from the 1960s TV comedy Hogan's Heroes) approached guard duty. They hear, see, and know nothing. And government regulators let them get away with it."
He notes in the editorial that "U.S. hospitals still aren't required to publicly report ED throughput times, ambulance diversions, or the number of patients who leave the ED without being seen."
Third: acculturation. ED physicians, he suggests, have "become gradually acclimatized to accept conditions that were once unacceptable. Thirty years ago, who among us would have envisioned diverting an ambulance carrying a critically ill patient? Today, the practice is commonplace."
Treating patients in a waiting room
As to whether treatment in an ED waiting room would constitute the unethical practice of medicine, Pines writes, "That depends. If there is a critical surge of patients, and an ED that is usually well-run is overwhelmed, then it is unethical to leave patients in the waiting room for long periods.
"What is unethical is for hospitals to create a regular situation where ED patients must be treated in the waiting room as part of regular ED operations," Pines writes.
Possible solutions
Asked what it will take to create a solution to the overcrowding dilemma and whether it requires some sort of pushback or revolt from ED health care providers, Kellerman tells MEA, "I don't know that there will ever be a limit to what physicians and nurses in ERs are willing to try to do to take care of the patients in front of them."
Kellerman recalled standing up at an Institute of Medicine annual meeting a few years ago and directing a question to a former Secretary of the U.S. Department of Health and Human Services, essentially asking if this individual thought "it was a good idea to push a group of health care providers to the point of exhaustion every day and every night in order to get the health care system through another 24 hours. And the individual responded by saying, 'I don't think it's appropriate for you to urge that health care providers go on strike.'"
One approach that has been endorsed by the American College of Emergency Physicians is "quite simple," Kellerman says.
"It just says if you don't have enough beds in the hospital, and you're boarding admitted, sick, and injured patients, who clearly are so ill that they require hospitalization in the hallways of your ER, that [it] is both more humane, safer, and more responsible to distribute that burden evenly through the hospital, which means, by definition, putting one or two patients under the nursing station in the hallway of an inpatient unit," he explains.
Pines suggests changes in the "fundamental way that hospitals function."
"The first and most effective way to reduce boarding," he writes, "is to reduce the variability in elective admissions. This is also called 'surgical smoothing.'
"Instead of operating on Monday to Thursday and then having few operations Friday and none on the weekend, some hospitals have moved to having a similar number of procedures throughout the week, including the weekends. Or, alternatively, pushing some elective cases to the weekends. What this does is to reduce the incidence of peaks in demand that are a major cause of ED boarding."
Kellerman tells MEA that it is up to HHS to determine solutions to this problem. For example, CMS, he says, is currently "considering adopting additional measures to begin to understand what's going on. There are some analyses in progress now that will allow one to look at a broad national picture. And there have been a handful of hospitals that have had the courage to study these issues within the walls of their facility."
"It would be one thing to complain about an unsolvable problem," Kellerman explains. "The fact is there are ready, current, effective strategies and solutions."
He says it will take a "collective awareness that this is compromising everyone's care, not just the poor, not just the minorities, and not just the uninsured. But, in fact, this is truly a nationwide problem."
"And second, and perhaps . . . the lever for this is going to be when people realize that you can't possibly be prepared for a disaster or a national emergency if the critical hospitals in your community can't even handle tonight's 911 calls and that light is starting to come on," he says.
Reference
Kellerman AL, "Waiting Room Medicine: Has It Really Come to This? Annals of Emergency Medicine. Doi:10.1016/j.annemergmed.2010.05.038.
Sources
- Arthur L. Kellerman, MD, MPH, Senior Researcher, Rand Corporation in Arlington, VA, and clinical professor of emergency medicine, Emory University School of Medicine, Atlanta, GA.
- Jesse M. Pines, MD, MBA, MSCE, Director, Center for Health Care Quality and Associate Professor of Emergency Medicine and Health Policy, George Washington University, Washington, DC.
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