Residents testify on ER overcrowding crisis
Bill would require reports on capacity, wait times
Patients are waiting days for treatment in emergency rooms across the state in an overcrowding crisis that health care professionals say is only growing worse. But the issue is there is no data to prove it.
On Monday, Connecticut lawmakers heard testimony on a bill that would require hospitals to report emergency department data, including bed capacity, patient counts and wait times. The proposal is part of an effort to address a statewide crisis that contributes to staff burnout, delayed diagnoses and adverse health outcomes for patients, according to clinicians.
One woman said she spent 52 hours in the hallway of Yale New Haven Hospital’s emergency department before doctors diagnosed her with meningitis in her brain and spine and Bell’s palsy.
A hospital resident said that 30 hours into waiting for an inpatient bed, a patient with dementia suffered an intercranial bleed after falling and striking their head during an attempt to get out of bed, requiring immediate surgery.
“This is a quality issue and care issue for the individuals, but there is a safety part,” state Sen. Saud Anwar, the chair of the Public Health Committee, said Monday at a public hearing on the bill. “It’s a matter of life and death when these things are happening.”
Senate Bill 181 would require the Department of Public Health, the Emergency Department Crowding and Boarding Workgroup and a representative of an association of hospitals in the state to evaluate and publish specific data points from each emergency department in the state.
The collection must include “bed capacity…the number of patients who received treatment… the number of emergency department patients who were admitted to the hospital…the average length of time from the patient’s first presentation to the emer
gency department until the patient’s admission to the hospital, and…the number of patients who were required to wait in the emergency department for an available bed in the appropriate unit of the hospital after being admitted to the hospital and the length of time each such patient waited in the emergency department for such available bed.”
Hospitals in the state advised lawmakers against the proposal, saying data collection alone will have no impact on overcrowding.
“I don’t want to give the impression that we need to have the data to solve this,” James Iacobellis, the senior vice president of government and regulatory affairs for the Connecticut Hospital Association, said Monday. “We know what some of these issues are and if we’re going to start to solve them, let’s solve them.”
For Iacobellis, those solutions include fixing the prior authorization system between insurance companies and healthcare providers, increasing the number of beds in emergency departments, examining Medicaid rates and expanding behavioral health and other services in the community.
Iacobellis cautioned that lawmakers should hold off on any action until the Emergency Department Crowding and Boarding Workgroup issues its recommendations to address the crisis.
Iacobellis said he is concerned that if the data collection bill passes and requires a budget appropriation, emergency departments will have a more difficult time securing additional funding for new initiatives.
“There isn’t a single bullet that will solve this issue,” Iacobellis said. “We believe that data collection will be part of this solution. However, we encourage the committee to wait until we get the full list of recommendations prior to acting upon one or another.”
Iacobellis said it is also difficult to gauge how much the data collection will add to hospital workloads.
“Is it flipping a switch or is it hundreds of hours?” Iacobellis said. “We don’t know where it falls, but it falls somewhere in between.”
Part of the issue, Iacobellis said, is that “there is not unanimity among the emergency department physicians about the collection of data.”
“You will probably see a majority of the emergency department physicians supporting this. However, there are some that will say it is going to be an additional burden and we can’t and we shouldn’t do that in isolation without solving the problem,” Iacobellis said.
Emergency room doctors who testified in support of the proposal Monday contested Iacobellis’ assertions, saying that most health records contain the information requested in the bill.
“While putting it in the right format — at least at first — will take some effort, most if not all of what we need should be readily available in the electronic health record,” Dr. Christopher Moore, an emergency physician at Yale New Haven Hospital said. “Particularly once the format is set, periodic exports that de-identify data should not be onerous and are very feasible.”
Moore, who is a professor of emergency medicine at Yale and serves as the co-chair of the Connecticut Emergency Department Boarding and Chronic Workgroup, said that anecdotally, overcrowding conditions have deteriorated, but there is no data to empirically demonstrate the change.
“We know ERS are crowded, but we do not know the details or the trajectories, which makes it hard to know where we’re going and what effect any interventions may have,” Moore said. “This is why it’s such a crucial first step.”
Moore said the overcrowding is not due to increased patient volumes but “boarding” — a term that Moore describes as a situation where “a decision has been made to admit a patient, but they remain in the emergency department for many hours or even days.”
In order to solve the problem, Moore said it is essential to know how often and why boarding occurs. In many cases, Moore said emergency departments board patients when the hospital decides to admit a patient to another facility or unit, but a lack of space or transportation prevents the patient from leaving.
“There’s a lot of demand for hospital space, for rehab space, for psychiatric treatment space, but the appropriate place for those people is not in the emergency department. It’s not the best place to care for them,” Moore said. “We need to figure out how to measure that and address it.”
While Yale’s emergency department holds 60 beds, Moore said roughly 30 to 50 patients are boarded every day. Moore said that in the past, the department has boarded more than 80 patients at a time.
“When that happens, we have no space to take care of anyone,” Moore said.
More than three dozen doctors, nurses and patients submitted testimony in support of the data collection bill. Stamford Health and Hartford Healthcare joined the Connecticut Hospital Association in opposing the proposal, arguing that data collection is not a solution to overcrowding.
In testimony submitted to the committee, Dr. Ken Robinson, the vice president of academic affairs of Hartford Healthcare, urged the committee to explore other overcrowding fixes, such as eliminating “delayed authorization for skilled nursing facility placement” and “non-ed care focused requirements like HIV testing.”
He also advocated for increased funding and support for Emergency Medical Services, shelters, detox facilities, behavioral health and addiction services, senior service and homecare and mobile integrated health care.
Robinson said data disclosures required in the bill could erode the public’s trust in emergency medicine. Robinson said mandating the publication of emergency departments’ bed capacity, stay length, and admission times could “adversely impact optimal patient care,” if a patient chooses to “erroneously seek care at a distant facility with a shorter reported boarding time,” instead of calling 911 or going to the closest hospital.
Moore said “The answer to a problem is not to sweep it under the rug, but to trust that with appropriate attention and scrutiny, we can all together work to solve it.”
He said the Emergency Department Crowding and Boarding Workgroup intends to present solutions within the next year, but he said “the healthcare system needs help,” and that starts with data collection.
“Make no mistake, this is a public health crisis,” Moore said. “The emergency department increasingly represents the place where all manner of health and social issues are addressed. …We are doing our best, but need help to understand, shed light and solve this crisis so that we can safely and effectively care for the citizens of Connecticut.”