5 ms·

The title should be changed. This has nothing to do with ER capacity (or the pandemic, for those commenters already leaping to that conclusion), and the author

by timr 2y ago

The title should be changed. This has nothing to do with ER capacity (or the pandemic, for those commenters already leaping to that conclusion), and the author admits 3/4ths of the way down the article that ER capacity is not the problem: > The primary problem is not the number of patients coming to the ER. It’s the lack of open beds upstairs. She goes on to explain that most of the problem is that hospitals keep their beds full so as to maximize profits, with a variety of reasons ranging from nursing home shortages to hospitals' tendency to prioritize elective surgeries (these make more money). In fact, this entire article is very bad. The author asserts a problem, but provides no actual data to support the assertion, other than linking to some tweets of other people's opinions (edit: I shouldn't have said tweets; these are mostly links to pop journalism and editorials). Here's a paper quantifying the boarding problem in hospitals in the US, during the worst part of the pandemic: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9526134/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9526134/ to wit: > Occupancy rates and boarding time had a threshold association: when occupancy exceeded 85%, boarding exceeded The Joint Commission 4-hour standard for 88.9% of hospital-months (Figure 1). In those hospital-months, median ED boarding time was 6.58 hours compared with 2.42 hours in other hospital-months (P < .001). Across all hospitals, the median ED boarding time was 2.00 hours (5th-95th percentile, 0.93-7.88 hours) in January 2020, 1.58 hours (5th-95th percentile, 0.90-3.51 hours) in April 2020, and 3.42 hours in December 2021 (5th-95th percentile, 1.27-9.14 hours).

SoftTalker 2y ago
New hospitals are being built with fewer beds than the ones they are replacing. The current objective in hospital medicine is to get the patient home as soon as possible. There's a lot of good reasons for that, hosiptals are disease cesspools. Basically if you don't need intensive care they want to send you home.
- timr 2y ago
  I don't know about the former part, but I agree with the latter completely. Turning people quickly from hospitals is a good thing. The longer you stay in a hospital, the more likely you are to die from something bad that happened to you in the hospital. But, it doesn't have anything directly to do with the so-called "boarding problem", which is what this article is about. That's mostly about the for-profit nature of our health care system, which is doing exactly what one would expect (optimizing profits).
  - solidsnack9000 2y ago
    Well, it's not exactly profits that are a problem here. The author points out that these hospitals are subject to regulation and that the regulation does not actually condition funding on spare capacity. That's just going to lead to broken results; doesn't matter whether it's for profit or not. A completely publicly funded healthcare system without spare capacity requirements would falter in the same way.
- shawn_w 2y ago
  There are even programs these days where people are sent home while still technically being admitted to a hospital, with a nurse coming by on a regular basis to administer medications, change dressings, provide other needed care, etc. Doctors are involved via teleconference when needed.
- FireBeyond 2y ago
  > New hospitals are being built with fewer beds than the ones they are replacing. Guess why? Because new hospitals need a Certificate of Need to be approved for construction. What's that? It's a process by which -other hospitals in the area- get to say whether a new facility should be built. In many cases, this means a fine tuning of things to make sure you maintain available beds across all hospitals just short of the actual need (because if your facility is going to absorb the need, and leave others with empty beds, then you ain't getting your certificate). This process was lobbied for by the hospitals themselves.
unyttigfjelltol 2y ago
Yes, the boarding phenomenon is a well-reported byproduct of closure of public inpatient mental health facilities, which in recent years met a surge of mental health crises. Mental health patients are really the only group ill enough to be admitted but which the system will not allocate resources to serve. See: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6754202/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6754202/ https://www.jointcommission.org/-/media/tjc/newsletters/quick-safety-19-ed-boarding-update-7-27-21.pdf https://www.jointcommission.org/-/media/tjc/newsletters/quic...
577710959 2y ago
> The author asserts a problem, but provides no actual data to support the assertion, other than linking to some tweets of other people's opinions. Here's the hosts linked to by the article: Object.entries(Object.groupBy(Array.from(document.querySelectorAll(".body a")).map(a => a.href.split("/")[2]), x => x)).map(([host, refs]) => [host, refs.length]) [ "www.acep.org", 4 ] [ "substackcdn.com", 3 ] [ "link.springer.com", 2 ] [ "onlinelibrary.wiley.com", 1 ] [ "papers.ssrn.com", 1 ] [ "catalyst.nejm.org", 3 ] [ "www.washingtonpost.com", 1 ] [ "mmshub.cms.gov", 2 ] [ "yalesurvey.ca1.qualtrics.com", 2 ] [ "youcanknowthings.com", 1 ] The article cites several published papers, as well as the American college of emergency physicians--I don't see twitter anywhere.
- timr 2y ago
  Domains mean nothing. Click on the very first link (ACEP; anchor text "sounding the alarm"), and you'll see that it's a news article (actually, an editorial) with no cited authors that I can find. It leads with this completely un-sourced assertion: > Wait times and staffing shortages are worse today than at any point during the pandemic in many communities. The resulting bottlenecks are overwhelming hospitals, causing dangerous delays, and putting lives at risk. Emergency care teams are strained to their limits. Demand for emergency care and services shows no signs of slowing as we head straight toward this winter’s “triple threat” of flu, COVID-19, and pediatric respiratory illnesses like RSV that are filling emergency departments. The influx of patients only piles more stress onto the shoulders of emergency physicians, who are doing all they can to treat anyone who needs them. Aside from leaning heavily on emotional wording ("strained to their limits", "doing all they can"), these kinds of claims are meaningless without data. The rest of the piece is no better -- it's just anecdote after anecdote, written in newspaper style. The second link is a poll of patients. That's data of some kind, I suppose, but it's not what you'd use to support the claim. That's the entirety of the evidence advanced to prove the fundamental claim that emergency rooms are "overwhelmed". Point being: I looked at the links before I wrote what I wrote. The "evidence" being used here is mostly opinions, surveys and editorials. It's a classic example of "evidence laundering", wherein someone links to pop articles on reputable-sounding domains to make bald assertions sound like rigorous research. I said "tweets" because I thought I saw a link to X in there, but I think I was wrong about that. Mea culpa.
FireBeyond 2y ago
As a paramedic in a major metro area... The ED in the larger hospital near me where we take most of our patients (a Level 2 Trauma Center which, for the benefit of simplification is essentially a Level 1, without teaching facilities attached) about 8 years ago (say 2-3 before COVID) had 4 "pods", A-D, A and B on one side, registration, waiting, intake, in the middle, and C and D on the other (they formed something of a horseshoe around the intake area). Each pod had 10 rooms (they don't have ward style multiple patients to a room). It used to be that C and D pods were "peak hours only", and after 3 or 4pm, there were no patients, and the lights were down. Then things changed. C and D pods run 24/7 now. And there are 24 "hallway beds" which are typically lower acuity patients literally on gurneys in the halls, one in front of each room. Then the psych holding area (5 secured rooms) started overflowing. Patients are now given gowns and scrubs based on their needs. A shocking number of the hallway beds are brown scrubs, which indicates mental health, often with a hold in place (i.e. they are not "free to leave", until evaluation and treatment plan has been determined, as a threat to themselves or others). Oftentimes this means finding an inpatient bed elsewhere. I have, tragically, watched frequent fliers with severe mental illness wait multiple days on a hallway bed. Nothing to read, watch, look at. No rest. No pause from the chaos. At least in a room, you can have a curtain drawn, lights dimmed. Not in the hallway. 24/7 we're wheeling patients by you as EMS, conversations at nursing stations. For me, perfectly "sane", that would drive me to the brink, to someone already in crisis ... The only "solution" that is compatible with that environment is sedation. (To be clear, it is not a solution, just the only one compatible then and there). > hospitals' tendency to prioritize elective surgeries (these make more money). At least this hospital, and a couple of others I know in the near region, hospitals have expanded their outpatient surgery and elective surgery, already in its own building, to include inpatient, too, so those patients are not taking up room for admissions out of the ED.
- timr 2y ago
  I believe you, and it's telling that this wasn't part of the OP's post. There are lots of reasons that ERs are seeing increasing load, and some of them support a left-wing argument, and others support a right-wing argument. The person doing the arguing will pick and choose their examples to fit their preferred narratives.

by timr 2y ago

SoftTalker 2y ago

New hospitals are being built with fewer beds than the ones they are replacing. The current objective in hospital medicine is to get the patient home as soon as possible. There's a lot of good reasons for that, hosiptals are disease cesspools. Basically if you don't need intensive care they want to send you home.

timr 2y ago
I don't know about the former part, but I agree with the latter completely. Turning people quickly from hospitals is a good thing. The longer you stay in a hospital, the more likely you are to die from something bad that happened to you in the hospital. But, it doesn't have anything directly to do with the so-called "boarding problem", which is what this article is about. That's mostly about the for-profit nature of our health care system, which is doing exactly what one would expect (optimizing profits).
- solidsnack9000 2y ago
  Well, it's not exactly profits that are a problem here. The author points out that these hospitals are subject to regulation and that the regulation does not actually condition funding on spare capacity. That's just going to lead to broken results; doesn't matter whether it's for profit or not. A completely publicly funded healthcare system without spare capacity requirements would falter in the same way.
shawn_w 2y ago
There are even programs these days where people are sent home while still technically being admitted to a hospital, with a nurse coming by on a regular basis to administer medications, change dressings, provide other needed care, etc. Doctors are involved via teleconference when needed.
FireBeyond 2y ago
> New hospitals are being built with fewer beds than the ones they are replacing. Guess why? Because new hospitals need a Certificate of Need to be approved for construction. What's that? It's a process by which -other hospitals in the area- get to say whether a new facility should be built. In many cases, this means a fine tuning of things to make sure you maintain available beds across all hospitals just short of the actual need (because if your facility is going to absorb the need, and leave others with empty beds, then you ain't getting your certificate). This process was lobbied for by the hospitals themselves.

unyttigfjelltol 2y ago

Yes, the boarding phenomenon is a well-reported byproduct of closure of public inpatient mental health facilities, which in recent years met a surge of mental health crises. Mental health patients are really the only group ill enough to be admitted but which the system will not allocate resources to serve. See: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6754202/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6754202/ https://www.jointcommission.org/-/media/tjc/newsletters/quick-safety-19-ed-boarding-update-7-27-21.pdf https://www.jointcommission.org/-/media/tjc/newsletters/quic...

577710959 2y ago

> The author asserts a problem, but provides no actual data to support the assertion, other than linking to some tweets of other people's opinions. Here's the hosts linked to by the article: Object.entries(Object.groupBy(Array.from(document.querySelectorAll(".body a")).map(a => a.href.split("/")[2]), x => x)).map(([host, refs]) => [host, refs.length]) [ "www.acep.org", 4 ] [ "substackcdn.com", 3 ] [ "link.springer.com", 2 ] [ "onlinelibrary.wiley.com", 1 ] [ "papers.ssrn.com", 1 ] [ "catalyst.nejm.org", 3 ] [ "www.washingtonpost.com", 1 ] [ "mmshub.cms.gov", 2 ] [ "yalesurvey.ca1.qualtrics.com", 2 ] [ "youcanknowthings.com", 1 ] The article cites several published papers, as well as the American college of emergency physicians--I don't see twitter anywhere.

timr 2y ago
Domains mean nothing. Click on the very first link (ACEP; anchor text "sounding the alarm"), and you'll see that it's a news article (actually, an editorial) with no cited authors that I can find. It leads with this completely un-sourced assertion: > Wait times and staffing shortages are worse today than at any point during the pandemic in many communities. The resulting bottlenecks are overwhelming hospitals, causing dangerous delays, and putting lives at risk. Emergency care teams are strained to their limits. Demand for emergency care and services shows no signs of slowing as we head straight toward this winter’s “triple threat” of flu, COVID-19, and pediatric respiratory illnesses like RSV that are filling emergency departments. The influx of patients only piles more stress onto the shoulders of emergency physicians, who are doing all they can to treat anyone who needs them. Aside from leaning heavily on emotional wording ("strained to their limits", "doing all they can"), these kinds of claims are meaningless without data. The rest of the piece is no better -- it's just anecdote after anecdote, written in newspaper style. The second link is a poll of patients. That's data of some kind, I suppose, but it's not what you'd use to support the claim. That's the entirety of the evidence advanced to prove the fundamental claim that emergency rooms are "overwhelmed". Point being: I looked at the links before I wrote what I wrote. The "evidence" being used here is mostly opinions, surveys and editorials. It's a classic example of "evidence laundering", wherein someone links to pop articles on reputable-sounding domains to make bald assertions sound like rigorous research. I said "tweets" because I thought I saw a link to X in there, but I think I was wrong about that. Mea culpa.

FireBeyond 2y ago

As a paramedic in a major metro area... The ED in the larger hospital near me where we take most of our patients (a Level 2 Trauma Center which, for the benefit of simplification is essentially a Level 1, without teaching facilities attached) about 8 years ago (say 2-3 before COVID) had 4 "pods", A-D, A and B on one side, registration, waiting, intake, in the middle, and C and D on the other (they formed something of a horseshoe around the intake area). Each pod had 10 rooms (they don't have ward style multiple patients to a room). It used to be that C and D pods were "peak hours only", and after 3 or 4pm, there were no patients, and the lights were down. Then things changed. C and D pods run 24/7 now. And there are 24 "hallway beds" which are typically lower acuity patients literally on gurneys in the halls, one in front of each room. Then the psych holding area (5 secured rooms) started overflowing. Patients are now given gowns and scrubs based on their needs. A shocking number of the hallway beds are brown scrubs, which indicates mental health, often with a hold in place (i.e. they are not "free to leave", until evaluation and treatment plan has been determined, as a threat to themselves or others). Oftentimes this means finding an inpatient bed elsewhere. I have, tragically, watched frequent fliers with severe mental illness wait multiple days on a hallway bed. Nothing to read, watch, look at. No rest. No pause from the chaos. At least in a room, you can have a curtain drawn, lights dimmed. Not in the hallway. 24/7 we're wheeling patients by you as EMS, conversations at nursing stations. For me, perfectly "sane", that would drive me to the brink, to someone already in crisis ... The only "solution" that is compatible with that environment is sedation. (To be clear, it is not a solution, just the only one compatible then and there). > hospitals' tendency to prioritize elective surgeries (these make more money). At least this hospital, and a couple of others I know in the near region, hospitals have expanded their outpatient surgery and elective surgery, already in its own building, to include inpatient, too, so those patients are not taking up room for admissions out of the ED.

timr 2y ago
I believe you, and it's telling that this wasn't part of the OP's post. There are lots of reasons that ERs are seeing increasing load, and some of them support a left-wing argument, and others support a right-wing argument. The person doing the arguing will pick and choose their examples to fit their preferred narratives.