Editorial - “All a-Board!”

The title of last month’s editorial, “A Night (and Week) to Remember!”, is an allusion to a famous book and movie about the sinking of the Titanic; the editorial that followed recounts the experiences of distinguished EP Charlotte Yeh, MD, after she had been struck by a car and became a patient in a busy Washington DC Level I trauma center. In Dr Yeh’s June 2014 article for Health Affairs she characterized her care as uneven and neglectful of her overall well-being. The care also appeared to be fragmented, sloppy, callous, and uncoordinated.

We did not comment last month on one aspect of her experience: after her radiologic studies were completed, Dr Yeh was brought back to the ED on a stretcher and parked in an ED hallway where she remained through the night, admitted but “boarding” in the ED waiting for an inpatient bed to become available. When the day crew that arrived 15 hours later recognized Dr Yeh as an EP, she was moved from the hallway to a private room. For Dr Yeh, being in an ED hallway was not the most significant problem associated with her ED care, but for most ED patients, being a hallway patient for many hours frequently overshadows all of the efforts of the many dedicated, hardworking EPs and nurses to provide our patients with the best care possible. Too often nowadays, the ED hallway has become the intersection of clinical care, comfort, length of stay, and patient satisfaction.

Ironically, Dr Yeh wrote that she “took comfort in being left in the hallway,” because to her “it meant that [she] was okay, that the hospital staff wasn’t so worried” about her and, conversely, after being moved to a darkened room with the door shut so that she could sleep, she felt abandoned.

Most patients in the overcrowded, urban, academic medical center EDs throughout the country prefer rooms—not hallways—until they are either discharged or admitted to an inpatient bed. Factoring in the constant noise and light, the uncomfortable ED stretchers, and the sometimes many hours spent in a hallway, is it any wonder that, nationwide, inpatient satisfaction scores of patients admitted through the ED are about 2 to 2.5 points lower than are those of patients admitted directly to an inpatient service? For many EPs and ED nurses, the hardest and most frequent decision they must make is whether to move a previously evaluated patient out of a room to a hallway, or to evaluate and treat a new patient outside of the room. Many factors contribute to this deplorable situation: ED overcrowding from other hospital closings, an increasing number of patients coming or sent to EDs because of the lack of primary care providers, and the growing number of patients waiting in EDs for inpatient isolation rooms. In fairness, the care of a patient on a hallway bed is not necessarily compromised. A 2012 Archives of Internal Medicine article questioned the assumption that favorable patient satisfaction scores correlate with quality of care; and bringing newly arrived patients into the ED as soon as possible, rather than making them wait in the waiting room for a room or cubicle to become available, certainly advances their care. But all that being said, why should so many patients have to spend time on hallway stretchers? If activities in EDs are closely integrated with activities in the rest of the hospital, the ED boarding situation can only improve significantly.

The title of last month’s editorial, “A Night (and Week) to Remember!”, is an allusion to a famous book and movie about the sinking of the Titanic; the editorial that followed recounts the experiences of distinguished EP Charlotte Yeh, MD, after she had been struck by a car and became a patient in a busy Washington DC Level I trauma center. In Dr Yeh’s June 2014 article for Health Affairs she characterized her care as uneven and neglectful of her overall well-being. The care also appeared to be fragmented, sloppy, callous, and uncoordinated.

We did not comment last month on one aspect of her experience: after her radiologic studies were completed, Dr Yeh was brought back to the ED on a stretcher and parked in an ED hallway where she remained through the night, admitted but “boarding” in the ED waiting for an inpatient bed to become available. When the day crew that arrived 15 hours later recognized Dr Yeh as an EP, she was moved from the hallway to a private room. For Dr Yeh, being in an ED hallway was not the most significant problem associated with her ED care, but for most ED patients, being a hallway patient for many hours frequently overshadows all of the efforts of the many dedicated, hardworking EPs and nurses to provide our patients with the best care possible. Too often nowadays, the ED hallway has become the intersection of clinical care, comfort, length of stay, and patient satisfaction.

Ironically, Dr Yeh wrote that she “took comfort in being left in the hallway,” because to her “it meant that [she] was okay, that the hospital staff wasn’t so worried” about her and, conversely, after being moved to a darkened room with the door shut so that she could sleep, she felt abandoned.

Most patients in the overcrowded, urban, academic medical center EDs throughout the country prefer rooms—not hallways—until they are either discharged or admitted to an inpatient bed. Factoring in the constant noise and light, the uncomfortable ED stretchers, and the sometimes many hours spent in a hallway, is it any wonder that, nationwide, inpatient satisfaction scores of patients admitted through the ED are about 2 to 2.5 points lower than are those of patients admitted directly to an inpatient service? For many EPs and ED nurses, the hardest and most frequent decision they must make is whether to move a previously evaluated patient out of a room to a hallway, or to evaluate and treat a new patient outside of the room. Many factors contribute to this deplorable situation: ED overcrowding from other hospital closings, an increasing number of patients coming or sent to EDs because of the lack of primary care providers, and the growing number of patients waiting in EDs for inpatient isolation rooms. In fairness, the care of a patient on a hallway bed is not necessarily compromised. A 2012 Archives of Internal Medicine article questioned the assumption that favorable patient satisfaction scores correlate with quality of care; and bringing newly arrived patients into the ED as soon as possible, rather than making them wait in the waiting room for a room or cubicle to become available, certainly advances their care. But all that being said, why should so many patients have to spend time on hallway stretchers? If activities in EDs are closely integrated with activities in the rest of the hospital, the ED boarding situation can only improve significantly.

The title of last month’s editorial, “A Night (and Week) to Remember!”, is an allusion to a famous book and movie about the sinking of the Titanic; the editorial that followed recounts the experiences of distinguished EP Charlotte Yeh, MD, after she had been struck by a car and became a patient in a busy Washington DC Level I trauma center. In Dr Yeh’s June 2014 article for Health Affairs she characterized her care as uneven and neglectful of her overall well-being. The care also appeared to be fragmented, sloppy, callous, and uncoordinated.

We did not comment last month on one aspect of her experience: after her radiologic studies were completed, Dr Yeh was brought back to the ED on a stretcher and parked in an ED hallway where she remained through the night, admitted but “boarding” in the ED waiting for an inpatient bed to become available. When the day crew that arrived 15 hours later recognized Dr Yeh as an EP, she was moved from the hallway to a private room. For Dr Yeh, being in an ED hallway was not the most significant problem associated with her ED care, but for most ED patients, being a hallway patient for many hours frequently overshadows all of the efforts of the many dedicated, hardworking EPs and nurses to provide our patients with the best care possible. Too often nowadays, the ED hallway has become the intersection of clinical care, comfort, length of stay, and patient satisfaction.

Ironically, Dr Yeh wrote that she “took comfort in being left in the hallway,” because to her “it meant that [she] was okay, that the hospital staff wasn’t so worried” about her and, conversely, after being moved to a darkened room with the door shut so that she could sleep, she felt abandoned.

Most patients in the overcrowded, urban, academic medical center EDs throughout the country prefer rooms—not hallways—until they are either discharged or admitted to an inpatient bed. Factoring in the constant noise and light, the uncomfortable ED stretchers, and the sometimes many hours spent in a hallway, is it any wonder that, nationwide, inpatient satisfaction scores of patients admitted through the ED are about 2 to 2.5 points lower than are those of patients admitted directly to an inpatient service? For many EPs and ED nurses, the hardest and most frequent decision they must make is whether to move a previously evaluated patient out of a room to a hallway, or to evaluate and treat a new patient outside of the room. Many factors contribute to this deplorable situation: ED overcrowding from other hospital closings, an increasing number of patients coming or sent to EDs because of the lack of primary care providers, and the growing number of patients waiting in EDs for inpatient isolation rooms. In fairness, the care of a patient on a hallway bed is not necessarily compromised. A 2012 Archives of Internal Medicine article questioned the assumption that favorable patient satisfaction scores correlate with quality of care; and bringing newly arrived patients into the ED as soon as possible, rather than making them wait in the waiting room for a room or cubicle to become available, certainly advances their care. But all that being said, why should so many patients have to spend time on hallway stretchers? If activities in EDs are closely integrated with activities in the rest of the hospital, the ED boarding situation can only improve significantly.