2005 News

The real solution to ED overcrowding

10.15.2005

There have been a number of studies and reports conducted on the issue of emergency department overcrowding and ambulance diversion that offer a number of alternative solutions, including one commissioned by the Department of Public Health, and none of them call for the placement of patients in hallways.

There are three root causes of the overcrowding problem in Massachusetts:

  1. Understaffing of registered nurses to allow for full utilization of existing hospital capacity to allow for efficient transfer of patients out of emergency departments onto inpatient units.
  2. A shortage of beds in the system due to hospital consolidation caused by the industry’s reliance on a cut-throat free-market model of health care delivery.
  3. A failure of hospital administrators to manage non-emergent, elective surgeries and admissions by physicians to control bed utilization and availability.


The solutions promoted by the MNA that responds to these root causes include:

  1. Passage of legislation to regulate RN-to-patient ratios in all acute care hospitals, which includes a ratio for nurses in the emergency department. This law will guarantee full staffing to allow for opening up of bed capacity to ease overcrowding; and it will end the current shortage of nurses who are refusing to work in hospitals because of the current conditions.
  2. Creation of a safe, properly-equipped holding area (not a hallway) for patients awaiting a bed on an inpatient unit. This area must be safely staffed with nurses dedicated to caring for those patients. In no instance should an ED nurse be assigned to cover treatment rooms in the ED and still be responsible for patients in a hallway.
  3. Staff to full-bed capacity as opposed to the current practice of providing staffing based on an estimated average daily census. Even with the loss of bed capacity in our state’s hospitals, in many instances, there are beds available for patients in the hospital; there are just no nurses available on that shift to staff the beds. The Institute of Medicine, in its groundbreaking report on nurse staffing and patient safety, recommends that hospitals overstaff units to account for and manage variability in patient flow.
  4. Mandating that hospitals take appropriate control of elective admissions or regulate suitable hospital discharge procedures to smooth admissions and allow for the capacity to handle spikes in emergency department utilization. The DPH commissioned a study by a team of Boston University researchers who have developed just such a system for hospitals. The program has been adopted by Boston Medical Center and has been working well. But no other hospital in Massachusetts is adopting these policies.
  5. Adequately staff ancillary departments to allow for rapid cleaning and turnaround of rooms. In many instances, there is a staffed bed available for a patient, but there is a delay in turning over the room.
  6. Ambulance diversion to a well-staffed hospital with the capacity to properly care for a patient is safer than overloading a hospital that is already filled to capacity, thus necessitating care in a hallway.
  7. The DPH needs to assess current and future bed capacity, and the state needs to ensure the provision of an appropriate number of beds throughout the state to provide safe, dignified care to the residents of the commonwealth.

The MNA continues to research methods of dealing with ED overcrowding that do not involve corridor care and will educate its members and the nursing community about these alternatives.

It will be conducting a survey of emergency department nurses to determine what hospitals across the state are doing to deal with this crisis and most important of all, it will be pushing for passage this year of legislation to regulate RN-to-patient ratios in hospitals, which is a lynchpin to a true system wide solution.

To review the MNA position statement on this issue, click here

The view from front-line nurses

“As a medical surgical nurse who often finds herself overloaded with very acutely ill and vulnerable patients, I find it hard to believe anyone who cares about the quality and safety of care in a hospital would even suggest boarding patients in the hallways of emergency departments or inpatient units. I can’t conceive of how I would be able to manage a normal case load of patients in rooms, and also be assigned a patient in the hallway. How could that patient have any privacy? How can I take a history? How can I maintain any semblance of compliance with HIPAA regulations with that patient out in the middle of the hall? And what happens with their family member? There are so many problems that could arise, including the total lack of infection control, not to mention the management of pumps and other equipment that the patient may need. It’s a recipe for disaster. This is not the solution. This is an insult to every patient who is forced to endure such care.”

—Marlena Pellegrino,RN, St. Vincent Hospital in Worcester

“Caring for patients in the hallways in and around our ED has become so common that there are now two permanently established beds that are used just for this purpose. These beds are each curtained off and they’re outfitted with the basic types of equipment that an RN would need to care for a patient . . . but they’re in a hallway! In addition, the hospital will add up to two more beds in the halls if they need to—all while they shuffle patients back and forth between ED rooms, hallway beds and waiting room chairs depending on what a patient’s condition and situation are.

“This situation has become the norm in our hospital, and it’s one that the patients don’t even recognize as dangerous and intrusive. It is also a situation that could potentially put my license in jeopardy. The mandate from hospital management is that we DO NOT transfer patients out, but caring for them in the halls goes against what I was trained to do in nursing school. Under these circumstances, I find that I begin each shift by hoping and praying that there won’t be a case that tips the scales—the type of case where I’ll have to fight with management over how and where this patient is cared for.”

—Diane George, RN, North Adams Hospital

“As an ED nurse for more than 20 years, I understand the frustration of colleagues who struggle every day to provide appropriate care in overcrowded emergency departments, having worked many a shift with stretchers in the halls, waiting for a bed to clear up on the units and floors. But as a patient advocate, I cannot and will not condone a practice that simply transfers the indignity of hallway care from my unit to another unit.

“As an MNA member for my entire career, I know the MNA has never condoned placing patients in hallways anywhere in the hospital. The problem with ED overcrowding isn’t about nurses being pitted against nurses, it’s a problem with administration.

“I know the reason a bed isn’t ready for my patient is because management hasn’t staffed or hired enough nurses to open that bed. I know it’s because my administrator hasn’t taken other steps such as postponing elective surgeries. I know that hospitals that could be going on diversion are choosing not to or are waiting too long to make the decision to go on diversion even though that would be the safe thing to do.

“It’s time for DPH and MHA to stop this policy and to work on solutions to deal with this crisis that aren’t based on pitting nurses against each other, and most important of all, that put patients’ care and well being first and foremost.”

—Linda Condon, RN, Quincy Medical Center

FPO