But two nights later, when I arrived for my next shift, I found the patient bleary-eyed on the same gurney where I had left her. “Dr. Z,” she begged me. “I’ve been here for two days!” “I still haven’t slept and I feel worse than when I came. When are you going upstairs?”
Her plight surprised me, but it didn’t surprise me. Emergency patients who require hospitalization routinely wait hours or even days for a bed. This is called “boarding”. Boarding is not new to the U.S. health care system, but the ripple effects of the pandemic have turned it from a problem to a crisis.
It is well documented that COVID-19 has devastated emergency departments across the country, exposing and exploiting vulnerabilities in the emergency medical system. But less has been written about the side effects of hospitals’ attempts to recover from that era. One of the most serious side effects is the proliferation of boarding schools. As hospitals scramble to regain footing (and profit margins), the financial incentive structure that underpins U.S. health care is becoming overstretched. Inpatient beds that might previously have been reserved for patients who require essential care but generate little revenue for the hospital, such as the 84-year-old woman, will now be allocated to patients undergoing more lucrative procedures. is increasing.
The impact of this systemic failure cannot be overstated. The maximum length of stay in the emergency department is four hours, but recent data shows that hospitals across the country are falling short of that goal when occupancy is high, which is typically the case. has been done. In my experience, the problem is deeper than the data suggests. I worked at Elmhurst Hospital in Queens, which was called the “epicenter of epicenters” of the outbreak in the United States. He also worked at two of the most prestigious university hospitals in the country. At all three hospitals, my emergency patient would often wait 10 hours, sometimes even 20 hours, for an inpatient bed. As expected, the most vulnerable suffer disproportionately. The majority of emergency physicians report that psychiatric patients wait days for beds. On any given shift, the emergency department hallways are lined with patients on stretchers. Boarding can cause harm, such as diverting ambulances to hospitals far from patients’ homes, charging patients for beds not yet occupied, and overwhelming paramedics who leave the scene due to burnout. It leads to a chain. Most alarming, evidence, including a 2023 study in JAMA, shows that emergency department boarding is associated with increased in-hospital mortality.
Many stories about boarding focus on the patients themselves, shaming some for inappropriately using the emergency department. Proposed solutions include transporting patients to emergency centers and changing “patient flow.” But boarding issues cannot be addressed with such small adjustments.
The solution is actually obvious. Use past years’ data to predict future enrollment needs and save money. Number of beds on the inpatient floor. Research shows this is possible and has already been successfully implemented in a small number of health systems. Administrators plan non-urgent procedures based on inpatient bed capacity. So instead of having knee replacement surgery on Monday, patients will be scheduled for Thursday, when hospitals are generally less busy. Physicians performing these procedures sacrifice some control over their schedules, but for many patients who require acute care, the rewards are great.
So why hasn’t this strategy been implemented across the country? Because it requires managers to change the way they run their healthcare businesses. When efficiency and profitability are guiding values, empty hospital beds are seen as waste and not a critical buffer to facilitate acute care. This model favors lucrative elective admissions and high-revenue procedures at the expense of acute emergency admissions. Therefore, the knee replacement surgery would take priority over my patient’s congestive heart treatment, and both would receive an inpatient bed before an unhoused patient who needed psychiatric care. Boarding is not an unfortunate byproduct of our health care system. It’s baked into the design.
To meaningfully impact change, new financial incentives are needed to better align essential public goods with privatized health systems. First, we need to recognize that boarding is not a commonly treated emergency department problem, but rather a system-wide failure. We need to rethink how hospitals can (and should) make money. If there were financial rewards for keeping a certain number of inpatient beds open, changes would occur not just in the emergency department. Not just for patients, but also for when the next public health crisis occurs and the demand for hospital beds spikes.
To find financial incentives, hospitals need to find partners. Engaging experts in finance, behavioral economics, and the insurance industry is a good start, but there are limits to what private industry can accomplish alone. Public-private models have also been successfully implemented in other sectors where public goods depend on the private sector. Consider the power grid or the military, where governments partner with private industry to provide our basic needs and protection.
For those of us working in the field, it is clear that we are failing to meet the basic needs of our communities.this is national health insurance We are in crisis and require a national response.