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Your Captain Speaking: We Need a Bed!
“Samantha, EMS is all about helping people, providing care and comfort—not just for our patients but for each other. There is a trend developing that goes against this for everyone. Recognizing there is a problem is needed before a solution can be attempted. The problem is boarding patients.”
EMS services as well as individual providers must have a plan to react to the problem of patient boarding before it happens to them. Do you have a protocol to follow? Have you had a discussion?
Defining Patient Boarding
Boarding patients can come in several forms, depending on which part of the medical care system you work in. Few patients know the term, but can suffer the consequences.
Here are a couple of examples.
A fairly routine call at a nursing home to transport a patient to the hospital for a laceration due to a fall, or perhaps a UTI. Once at the hospital, you are advised to wait with the patient as there are no rooms or staff available to take report. You wait and hours go by.
In another case, the ED physician sees a patient and decides that the best course of action is admit the patient to the hospital. But there are simply no beds or staff available, so the patient is placed in the ED hallway. Sometimes the wait is measured in days.
Dangerous Precedent
Patient boarding is not just a denial of good medical care. It’s a denial of service to others in the community when EMS support is unavailable.
Two recent events placed the problem in the national spotlight. A 2022 letter to President Biden from the American College of Emergency Physicians and other influential organizations stated the following.
Mr. President:
There is no question that Americans have suffered great loss of life and endured financial hardships, across all sectors, over the past 32 months due to the COVID-19 pandemic. Frontline healthcare workers risked their lives, provided care during physically and emotionally demanding situations, and bore witness to their patients’ goodbyes to loved ones from afar.
Yet, in recent months, hospital emergency departments (EDs) have been brought to a breaking point. Not from a novel problem—rather, from a decades-long, unresolved problem known as patient “boarding,” where admitted patients are held in the ED when there are no inpatient beds available.1
How many ambulances and crews should you have on duty at any given time? From a business perspective, it makes sense to have ambulances fully occupied with patients all the time. Ambulances and crews are expensive to just sit without an assignment.
Picture a hospital manager looking at an ED staff with physicians, nurses, supporting areas such as cath labs and X-ray departments that are only at 50% capacity. The manager would likely say that the ED has too many rooms and too much overhead staff. All businesses make these supply and demand decisions.
The letter is from the ED perspective and certainly valid. But there is more to the story when we take an EMS perspective.
It’s doubtful that when EMS receives a nonemergent call for a transfer that they will include the remark “You’ll probably have to wait for hours with the patient in the hallway until they can be seen.” Even on a 9-1-1 call, we can wait until the ED staff can accept the handover.
By no means are we suggesting the ED staff is not working hard and stretched to the limit. But this scenario puts us out of service and the continuation of care screeches to a halt. Raise your hand if you’ve been told to “just take them out to the waiting room.” Our personal discomfort as well as the legal aspects of abandonment are significant.
Consider the following scenario. You are the shift supervisor at an EMS company or perhaps a fire department. The phone rings and the nurse in charge at the nearby hospital asks you to send crews over to the ED to help them as they are overwhelmed. What is your answer?
Here’s an excerpt from a news article with an interesting twist. The call came from 9-1-1 dispatch.
“The charged nurse from inside the emergency room called 9-1-1,” said Central Kitsap Fire and Rescue Chief Jay Christian. “The charging nurse said twice, 'we’re drowning,' conveying that they only had five nurses on duty and 45 patients in their waiting room, and she was asking for help from local firefighters to come work inside of the ER to help relieve some of that pressure.”2
Difficult Questions
Like many of you our heart aches to read this story. But it’s a real situation we need to consider. There are some likely questions you’d ask on the telephone but it boils down to way too many patients, not enough staff, not enough rooms or beds. If you have no predetermined protocol, you’re in a very hard place.
Here are just a few questions that must be considered before answering this call. In no case are you going to have perfect and complete information.
- How many units and staff can I send and still cover my contractual commitments?
- Who’s paying for this?
- Is the EMS medical director in the decision loop?
- How long will you need them? If they work past their shift times, will they be paid overtime? What’s a maximum work day?
- What is the medical-legal liability? Medical authority?
- Is the hospital on diversion? If not, it might influence your thought process.
- What supplies do we need to bring, such as PPE? What level of qualifications are needed?
- If the call is from the 9-1-1 dispatcher, do we have a choice to refuse?
There are many examples in which the hospital facilities and staff become overwhelmed. How big is the problem? We have no metrics but lots of personal experiences.
Where are the choke points in the system? We must consider whether any specific groups are disproportionately affected.
Have you ever had a patient call 9-1-1 because they didn’t want to wait in the ED waiting room? The crisis identified by ACEP developed for multiple reasons and EMS will be adversely affected without our involvement. There is not yet a clear-cut definition of medical boarding. What is an excessive waiting time? Is it even being tracked? Is it related to the patient’s condition?
Do You Have a Plan?
The issue of patient boarding is not just an inconvenience for patients but could affect long-term physical and mental health as well. Does your EMS service have a protocol for waiting with a patient? Does your fire or ambulance service have a plan if a hospital or mental health facility calls asking for assistance directly or via 9-1-1?
“Dick, you’re right. There are things we can do to educate our crews on what to do if asked to wait with a patient—specifically, advise their dispatcher and provide updates. Dispatchers need procedures. Supervisors establish protocols in concert with medical control and are brought into the loop as the situation develops. The boarding problem is not going away anytime soon.”
References
1. Letter to President Joseph Biden dated November 7, 2022. American College of Emergency Physicians and 34 other signatories. https://www.acep.org/globalassets/new-pdfs/advocacy/emergency-department-boarding-crisis-sign-on-letter-11.07.22.pdf
2. Silverdale hospital short on staff calls 9-1-1 for help after being overwhelmed with patients. Lionel Donovan, Tacoma Bureau Chief, King5, October 11, 2022. https://www.king5.com/article/news/local/staffing-issues-silverdale-hospital-calls-911/281-67b1f713-5775-400e-8fd3-e37fc35c5bd3
Dick Blanchet worked as a paramedic for Abbott EMS for more than 22 years. He was also a captain with Atlas Air for 22 years and a USAF pilot for 22 years.
Samantha Greene is a paramedic and field training officer for the Illinois Department of Public Health, paramedic and FTO for Columbia (Ill.) EMS, and a paramedic at the St. Louis South City Hospital Emergency Department.
Comments
Over 40 years as a NYC medic and things have not changed and are probably getting exacerbated all over again. Even though we had the right to refuse transport w medical control permission. It’s a slippery slope. I feel for the doctors, nurses and patients but they are not going to build more hospitals probably. Many years ago, I had a nurse hold the door closed to the ER and shortly a PR nightmare and the creation of the Hevsi Act which I don’t believe solved anything. Unless it has changed, NYS article 28 requires EMS transport directly to ER’s and not free standing clinics etc!
—Peter Hosey