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Emergency room boarding threatens patient safety

Boarders are in a dangerous limbo

The physician chair of emergency medicine at a major East Coast academic medical center recently shared with me that his facility’s emergency department (ED) was over capacity.

Hospitals are licensed with a set number of staffed beds. By staffed that means a hospital should have adequate nursing and medical staff on duty to take care of patients assigned to its licensed beds.

The ED physician explained that his hospital has around 75 emergency room (ER) beds, all of which were full. On top of that, though, they had another 80+ patients waiting in every hallway, nook, and cranny of the ER, waiting for a regular bed to become available.

ER boarding

In the healthcare industry, this is referred to emergency department boarding. It’s become such a strain on hospital human and facility resources that members of the American College of Emergency Physicians and other professional organizations wrote to The White House yesterday to sound the alarm.

The letter to President Joe Biden started off with a quote from an anonymous emergency physician who explained that during peak times his or her facility had more boarding patients than staffed beds. The doctor lamented that patients died in the waiting room while awaiting treatment and that it was “entirely due to boarding.”

Pending transportation

In a Texas medical malpractice case that we’re currently handling, emergency department boarding is a significant issue. The ER physician consulted with other medical specialists and determined that the patient—let’s call him Harrison—should be admitted to the intensive care unit (ICU).

Once that decision was made, the ER doctor called the ICU and spoke with a nurse practitioner, who agreed to accept Harrison as an ICU patient. About 30 minutes later, the ICU nurse practitioner went to the ED and assessed Harrison. She documented admission order and then went back to the ICU.

Around the same time, the ER physician noted in the electronic medical record that Harrison was an ED boarder. At that hospital, this unfortunately meant that Harrison was in a limbo zone. While boarding in the ED, waiting to be transported to an ICU bed, Harrison went into respiratory arrest and developed a brain injury. Its unclear what the ER nurse was doing when this happened, but she was definitely not in Harrison’s room, despite his grave condition.

During the depositions in the case, the ER physician said the ICU nurse practitioner was in charge and calling the medical shots, even though she was on another floor of the hospital at the time. The nurse practitioner from the ICU said that the ER physician remained in charge until the patient actually showed up in the ICU.

Meanwhile, both the ER doctor and ICU nurse practitioner were entering orders for the patient. Some of them conflicted with each other. When Harrison started having serious breathing problems, a respiratory therapist drew blood for an arterial blood gas analysis. The laboratory called in the critical results to the ICU nurse practitioner, rather than the ER doctor.

Harrison was left in limbo and left with a brain injury because of ER boarding and a hospital that had shoddy organization and training on how to monitor and manage these vulnerable patients.

The physician letter to The White House noted several causes for the ED boarding crisis that’s severely impacting patient care and safety. Two of the causes stuck out to me:

• Hospitals need to hire and train an adequate number of nurses to staff their beds. Some hospitals have been chronically understaffed, and this problem is a lot older than the worn-out excuse of the pandemic.

• Another concerning issue is misaligned incentives. Medicare and Medicaid guidelines (which also impact the way private insurance companies handle claims) pay more for elective (planned) hospital admissions than unplanned ER admissions. That creates a financial incentive for hospital leaders and bean counters to prioritize scarce beds for elective patients, even though patients being admitted through the ER might have a higher need.

If you’ve been seriously injured because of poor hospital emergency department care in Texas, then contact a top-rated, experienced Texas medical malpractice attorney for a free strategy session concerning your potential case.

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him by calling 281-580-8800 or emailing him right now.


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