Spending the Night in the ED Might Kill You

A new study suggests long stays in the Emergency Department, instead of being sent to the regular hospital, are associated with higher mortality.

As a consulting nephrologist, I go all over the hospital. Medicine floors, surgical floors, the ICU – I’ve even done consults in the operating room before. And, more and more, I do consults in the Emergency Department.

The reason I am doing more and more consults in the Emergency Department is not because the ED docs are getting gun shy with creatinine increases – it’s because patients are staying for extended periods in the Emergency Department despite being formally admitted to the hospital – a phenomenon known as boarding - because there are simply not enough beds. You know the scene if you have ever been to a busy hospital – the ED is full to breaking, with patients on stretchers in hallways, it can often feel more like a warzone than a place for healing.

This is a huge problem.

The Joint Commission specifies that admitted patients should spend no more than four hours in the ED waiting for a bed in the hospital.

That is, based on what I’ve seen, hugely ambitious.  But I should point out that I work in a hospital that runs near capacity all the time, and that studies – from some of my Yale Colleagues actually - have shown that once hospital capacity exceeds 85%, boarding rates skyrocket.

And I want to dig into some of the causes of extended boarding, and some solutions, but before that, I should probably prove to you that this really matters, and for that we are going to dig into a new study which suggests that ED boarding kills.

To put some hard numbers to the boarding problem, we turn to this paper out of France, appearing in JAMA Internal Medicine.

This is a really unique study design. Basically, on a single day – December 12th, 2022 – researchers fanned out across France to 97 Emergency departments and started counting patients.

The study focused on those older than age 75 who were admitted to a hospital ward from the ED. The researchers then defined two groups – those who got sent up to the hospital before midnight, and those who spent at least midnight to 8am in the ED (basically, people forced to sleep in the ED for a night).  The middle-ground people who were sent up between midnight and 8am were excluded.

The baseline characteristics between the two groups of patients were pretty similar – median age around 86, 55% female. There were no significant differences in comorbidities.

That said, comporting with prior studies, people in an urban ED, an Academic ED, or a busy ED were much more likely to board overnight.

So what we have are two similar groups of patients treated quite differently. Not quite a randomized trial, given the hospital differences, but not bad for purposes of analysis.

And here’s the most important numbers from the trial. Inpatient Mortality – 15.7% among those who spent the night in the ED, 11.1% for those who were sent up to the floor.

This difference held up even after adjustment for patient and hospital characteristics. Put another way, you’d need to send 22 patients to the floor instead of boarding in the ED to save one life. Not a bad return on investment.

It’s not entirely clear what the mechanism for the excess mortality might be, but the researchers note that patients kept in the ED overnight were about twice as likely to have a fall during their hospital stay – not surprising given the dangers of gurneys-in-hallways, and the sleep deprivation trying to rest in a busy ED engenders.

I should point out that this could be worse in the US. French ED docs continue to care for admitted patients boarding in the ED, whereas in many hospitals in the US, admitted patients are the responsibility of the floor team, regardless of where they are – making it more likely that these individuals may be neglected.

So, if indeed boarding in the ED is a life-threatening situation, why do we do it? What conditions are there that predispose to this?

You’ll hear a lot of talk, mostly from hospital administrators, saying that this is simply a problem of supply and demand. There are simply not enough beds for the number of patients who need beds. And staffing shortages don’t help either.

Though they never really want to talk about the reasons for the staffing shortages, like poor pay, poor support, and, of course, the moral injury of treating patients in hallways.

But yes, the issue of volume is real – and we could do a lot to prevent ED visits and hospital admissions by providing better access to preventative and primary care and an improvement in our outpatient mental health infrastructure but I think this framing passes the buck a little.

One other reason ED boarding occurs is due to the way our healthcare system is paid for. If you are building a hospital, you have little incentive to build in excess capacity. The most efficient hospital, from a profit and loss standpoint, is one that is 100% full as often as possible. That may be fine sometimes, but throw in a respiratory virus or even a pandemic, and those systems fracture under the pressure.

Let us also remember that not all hospital beds go to people who acutely need a hospital bed. Many beds, in many hospitals, are necessary to handle post-operative patients undergoing elective procedures. Those patients benefitting from knee replacement or abdominoplasties don’t spend the night in the ED when they leave the OR – they go to a hospital bed.  And those procedures are, let’s face it, more profitable than an ED admission for a medical issue. That’s why, even when hospitals expand the number of beds they have, they do it with an eye towards increasing the rate of those profitable procedures, not decreasing the burden faced by their ED.

For now, the band aid to the solution might be to better triage individuals boarding in the ED for floor access – prioritizing those of older age, greater frailty, or more medical complexity. But it feels like a stop-gap measure so long as the incentives are aligned to view an empty hospital bed as a sign of failure in the health system instead of success.

A version of this commentary first appeared on Medscape.com.