It's a problem across the US
Liv Osby, The Greenville News - July 8, 2019
When Maggie Miller’s husband, Ron, collapsed at their Pickens County home last month two days after same-day surgery, an ambulance rushed him to Prisma Health Baptist Easley Hospital. In the ER, the doctor concluded that the 80-year-old needed to be admitted.
There was just one problem. No beds were available.
What’s more, Miller said she was told he could not be transferred to Prisma Health Greenville Memorial Hospital or Bon Secours St. Francis Downtown because there were no available beds there either.
“I was just stunned,” she told The Greenville News.
“They were telling me there was no way they could admit him. That he had to stay in the ER,” she added. “There was no room.”
The phenomenon, called boarding, occurs when hospitals hold patients in the ER until they find a bed for them on a medical floor. It’s a growing problem across the nation, fueled in part by the national shortage of doctors and nurses, said Ryan Stanton, an ER physician with Central Emergency Physicians in Lexington, Kentucky, and a spokesman for the American College of Emergency Physicians. And Greenville — where hospitals say they are seeing record numbers of patients as the area continues to boom — is no exception.
The issue might seem complex, but it boils down to supply and demand – too many patients for the available beds, Dr. Ryan Hoffman, medical director of emergency services at Bon Secours St. Francis Health System, said via email.
"With all the construction and cranes across Greenville, we have not seen a significant increase in the number of hospital beds in the area,” Hoffman said.
There is also the question of whether patients who are told they need to be admitted but have to stay in the ER for hours longer get the same level of care as if they'd gotten a bed in the unit best equipped to handle their medical issue.
Some medical experts say boarding can affect the quality of care. Miller said it took 36 hours before a room became available for her husband, who wound up being hospitalized for three days.
Dr. C. Wendell James III, chief clinical officer for the region of Prisma Health-Upstate, formerly Greenville Health System, that includes Greenville County, said via email that the hospital is seeing record numbers of patients as the population grows and ages, all as hospitals struggle with the provider shortage. Stanton describes the situation this way:
“They’re trying to fill the bathtub with the ocean and it doesn’t matter how big the bathtub is. The health care system is inadequate for the demand. And it will get worse.”
A challenging environment
In a loud and busy ER, where nurses are constantly attending to new patients, it’s challenging to give the same level of time and attention to boarding patients that is provided in traditional inpatient units, Stanton said.
Nancy Foster, vice president of quality and patient safety at the American Hospital Association, said the best place for patients who require inpatient care is in an inpatient bed that is fully equipped to meet their needs. But "when that is not possible because inpatient beds are full," she added, "hospitals continue to care for patients in the emergency department until a bed is found."
When it comes to billing in these circumstances, in general, boarded patients are billed ER rates for the initial encounter and inpatient rates once they’ve been admitted even though they remain in the ER, said Chuck Alsdurf, a policy director at the Healthcare Financial Management Association, a nonprofit group for health care finance executives. If they're held in observation, they could be billed a mix of ER and observation rates, he said.
Hoffman said there are a few other reasons that make boarding a strategy for a lot of hospitals.
Patients admitted today are sicker and have more medical, physical and social needs that require more time in the hospital to resolve, he said, also via email. And conditions that were fatal years ago — such as strokes and traumatic injuries — are survivable today thanks to medical advances, but mean longer and often more frequent hospital stays, he added.
In addition to the shortage of health care providers, beds at nursing homes and other long-term care facilities where patients may need to go after release are also in short supply, he said.
It all results in a bottleneck that impacts the number of available beds.
“We are full and holding in the (ER) most weekdays,” Hoffman said. “It does have some seasonality to it. We tend to be busier in the winter due to flu and respiratory problems. But the ‘slow’ times are less frequent and shorter.”
“If the back end process breaks down,” said Stanton, “the front end will slow as well.”
According to the American Hospital Association, there are 6,210 hospitals across the nation with 931,203 total staffed beds to care for more than 36 million admissions a year.
While each market is different, boarding is a particular problem at large urban hospitals, said Dr. David Blumenthal, president of The Commonwealth Fund, a nonpartisan, nonprofit private foundation that supports health-care research. In addition to the shortage of staff and nursing home beds, the rise of antibiotic-resistant infections in recent years has also forced hospitals to isolate patients and perform elaborate decontamination processes, reducing the effective capacity without reducing the number of beds, he said. And that can slow the turn-around of ICU beds, for instance, he added.
In the Palmetto State, the situation is hit or miss, said Allan Stalvey of the South Carolina Hospital Association. A small rural hospital may have only two patients, he said, while an urban hospital is at capacity. It’s difficult to find staff because of the workforce shortage, especially in rural areas, Stalvey said. And if you don’t have enough doctors and nurses to take care of the patients in a particular area, then you can’t put patients there, he said.
Volumes going up
Nationwide, the incidence of boarding ranges from never at some hospitals to 1,000-plus hours a day at others and is growing, Stanton, of the emergency physicians group, said.
“With the aging population and increased demands on the health care system, volumes continue to go up,” he said. “But it’s too common to use the ER as the purge valve to park patients.”
And that means patients with less acute conditions can wait longer to be seen in the ER, he said.
Boarding became such an issue in 2016 at the University of Mississippi Medical Center that it led them to develop a new system to deal with it, said Dr. Alan Jones, chairman of the Department of Emergency Medicine. Because it’s a large, 700-bed academic medical center with all the specialty services, it’s a natural referral center for hospitals that may not have a full complement of staff or specialty beds, he said.
While it accepts any patient who arrives by ambulance, it uses a communications center to track bed status at other area hospitals, he said. That allows facilities that are looking to transfer a patient to send them to the hospital that can best accommodate them, Jones said.
“We’re a trauma center and when we get a call to accept a trauma, we want to make sure we can do that, that we don’t have a pneumonia who can be treated at another center," he added. "It does help.”
While there are times when all the hospitals in the area have the same problem, it tends to be more of an issue at the larger facilities, Jones said.
“It’s a very common scenario around the U.S.,” he said.“The whole system is overtaxed.”
UMMC also deals with a shortage of nursing home beds, he said. And although the shortage of doctors and nurses is an issue in many places, there it’s less of a concern than the fact that hospitals in the area are closing for financial reasons, leaving those that remain to care for the displaced patients, he said.
“We’ve been fortunate that we’ve been able to keep our beds fully staffed,” he said. “We never stop hiring.”
Strategies to cope
St. Francis uses a variety of strategies to deal with the problem, Hoffman said.
Patients with complex medical issues are assigned case managers early in their stay who are tasked with discharge planning so when patients leave the hospital, they get the services they need, whether that’s a nursing home, rehab, supplies, equipment or home care, he said.
Also, the hospital encourages providers to see patients early in the day so those going home can be discharged to free up beds, he said.
“When the hospitals are full, we send notices to admitting physicians asking them to discharge patients,” he said, “(and) defer transfers from outlying hospitals.”
And as a last resort, Hoffman said, they divert ambulance traffic to other facilities — although that's a short-term fix because other ERs fill up too — or delay elective admissions and surgeries.
St. Francis regularly assesses its needs, a hospital spokeswoman said, and is in the process of relocating and expanding the ER at its downtown campus to more than double ER capacity.
Prisma, meanwhile, is investing in infrastructure, innovative care models and educational partnerships to deal with the situation, James said. For instance, ERs are being expanded at Greenville Memorial, Baptist Easley and Oconee Memorial, he said, and Greenville Memorial is redesigning how it operates to better manage the growing volume of seriously ill patients. Initiatives to reduce boarding include adding seven more private treatment rooms and another triage room as part of Greenville Memorial's new ER design, James said. The project will enhance the ability to evaluate and discharge patients quickly, he said, and could free up as many as 30 to 40 inpatient beds.
Prisma also is investing in increased primary care and community health programs to reduce the need for hospital care, such as opioid-treatment outreach and community-based paramedics, he added. And Baptist Easley has added social workers in the ER to identify what patients need and connect them with services, James said. It also continues to recruit nurses, he said.
Oconee Memorial, meanwhile, is scheduled to break ground this fall for its ER expansionto add 22 new private treatment rooms to its existing 20 beds and almost triple the department’s footprint from 8,400 square feet to about 22,000, he said.
The new ER, which will take about two years to complete, will include a fast-track unit for patients with less urgent issues and a unit for patients with more urgent or complicated issues, allowing everyone to be seen more quickly, James said.
Prisma is also working with academic partners like Clemson and the University of South Carolina to train more doctors, nurses and other providers, he said.
Spartanburg Regional Healthcare System also said via email that to address its growing volume of patients, it added a new pavilion with more than 50 beds at Spartanburg Medical Center in 2017 and acquired Mary Black Health System this year.
At AnMed Health in Anderson, Chief Nursing Officer Shaunda Trotter said there’s currently no problem with available beds.
“However, there are seasons in which that may occur,” she said via email. “When it does occur, we have processes in place to work through the seasonal challenge."
Looking to the future
All the long-term solutions to boarding, such as building new facilities and adding beds, cost a lot of money and often take years to accomplish, Hoffman said.
“Then (health care) costs go up and people are upset about that too,” Stanton said.
And because South Carolina is a Certificate of Need state, hospitals must apply for approval to add beds or buildings — a process that can take months or years and may be denied.
However, in Greenville, Pickens and Anderson counties, there are no pending applications to add general hospital beds, according to the state Department of Health and Environmental Control, and no applications for more beds have been denied in the last five years.
In an effort to address its needs, UMMC recently opened a 13-bed unit in an existing patient tower and has plans for another unit in the next year or so that will add 32 more beds, Jones said. But the new unit was full the day it opened, he said.
“We will probably need more than that in the next three to five years if we continue to see the same volume of patients,” Jones said. “It’s only going to intensify.”
Miller said that after her husband's collapse that Sunday, she saw the ER was packed. He was released the following Wednesday and has been improving ever since, she said. But it was an eye-opening experience.
“The quality of care is not the issue. There’s a bottleneck that does not allow for inpatient care ... and whether it’s because of no beds or no staff, it still becomes a crisis,” she said.
“Either we need to train more nurses or be building more hospitals,” she added. “But we need to get it fixed.”
Liv Osby, The Greenville News - July 8, 2019
When Maggie Miller’s husband, Ron, collapsed at their Pickens County home last month two days after same-day surgery, an ambulance rushed him to Prisma Health Baptist Easley Hospital. In the ER, the doctor concluded that the 80-year-old needed to be admitted.
There was just one problem. No beds were available.
What’s more, Miller said she was told he could not be transferred to Prisma Health Greenville Memorial Hospital or Bon Secours St. Francis Downtown because there were no available beds there either.
“I was just stunned,” she told The Greenville News.
“They were telling me there was no way they could admit him. That he had to stay in the ER,” she added. “There was no room.”
The phenomenon, called boarding, occurs when hospitals hold patients in the ER until they find a bed for them on a medical floor. It’s a growing problem across the nation, fueled in part by the national shortage of doctors and nurses, said Ryan Stanton, an ER physician with Central Emergency Physicians in Lexington, Kentucky, and a spokesman for the American College of Emergency Physicians. And Greenville — where hospitals say they are seeing record numbers of patients as the area continues to boom — is no exception.
The issue might seem complex, but it boils down to supply and demand – too many patients for the available beds, Dr. Ryan Hoffman, medical director of emergency services at Bon Secours St. Francis Health System, said via email.
"With all the construction and cranes across Greenville, we have not seen a significant increase in the number of hospital beds in the area,” Hoffman said.
There is also the question of whether patients who are told they need to be admitted but have to stay in the ER for hours longer get the same level of care as if they'd gotten a bed in the unit best equipped to handle their medical issue.
Some medical experts say boarding can affect the quality of care. Miller said it took 36 hours before a room became available for her husband, who wound up being hospitalized for three days.
Dr. C. Wendell James III, chief clinical officer for the region of Prisma Health-Upstate, formerly Greenville Health System, that includes Greenville County, said via email that the hospital is seeing record numbers of patients as the population grows and ages, all as hospitals struggle with the provider shortage. Stanton describes the situation this way:
“They’re trying to fill the bathtub with the ocean and it doesn’t matter how big the bathtub is. The health care system is inadequate for the demand. And it will get worse.”
A challenging environment
In a loud and busy ER, where nurses are constantly attending to new patients, it’s challenging to give the same level of time and attention to boarding patients that is provided in traditional inpatient units, Stanton said.
Nancy Foster, vice president of quality and patient safety at the American Hospital Association, said the best place for patients who require inpatient care is in an inpatient bed that is fully equipped to meet their needs. But "when that is not possible because inpatient beds are full," she added, "hospitals continue to care for patients in the emergency department until a bed is found."
When it comes to billing in these circumstances, in general, boarded patients are billed ER rates for the initial encounter and inpatient rates once they’ve been admitted even though they remain in the ER, said Chuck Alsdurf, a policy director at the Healthcare Financial Management Association, a nonprofit group for health care finance executives. If they're held in observation, they could be billed a mix of ER and observation rates, he said.
Hoffman said there are a few other reasons that make boarding a strategy for a lot of hospitals.
Patients admitted today are sicker and have more medical, physical and social needs that require more time in the hospital to resolve, he said, also via email. And conditions that were fatal years ago — such as strokes and traumatic injuries — are survivable today thanks to medical advances, but mean longer and often more frequent hospital stays, he added.
In addition to the shortage of health care providers, beds at nursing homes and other long-term care facilities where patients may need to go after release are also in short supply, he said.
It all results in a bottleneck that impacts the number of available beds.
“We are full and holding in the (ER) most weekdays,” Hoffman said. “It does have some seasonality to it. We tend to be busier in the winter due to flu and respiratory problems. But the ‘slow’ times are less frequent and shorter.”
“If the back end process breaks down,” said Stanton, “the front end will slow as well.”
According to the American Hospital Association, there are 6,210 hospitals across the nation with 931,203 total staffed beds to care for more than 36 million admissions a year.
While each market is different, boarding is a particular problem at large urban hospitals, said Dr. David Blumenthal, president of The Commonwealth Fund, a nonpartisan, nonprofit private foundation that supports health-care research. In addition to the shortage of staff and nursing home beds, the rise of antibiotic-resistant infections in recent years has also forced hospitals to isolate patients and perform elaborate decontamination processes, reducing the effective capacity without reducing the number of beds, he said. And that can slow the turn-around of ICU beds, for instance, he added.
In the Palmetto State, the situation is hit or miss, said Allan Stalvey of the South Carolina Hospital Association. A small rural hospital may have only two patients, he said, while an urban hospital is at capacity. It’s difficult to find staff because of the workforce shortage, especially in rural areas, Stalvey said. And if you don’t have enough doctors and nurses to take care of the patients in a particular area, then you can’t put patients there, he said.
Volumes going up
Nationwide, the incidence of boarding ranges from never at some hospitals to 1,000-plus hours a day at others and is growing, Stanton, of the emergency physicians group, said.
“With the aging population and increased demands on the health care system, volumes continue to go up,” he said. “But it’s too common to use the ER as the purge valve to park patients.”
And that means patients with less acute conditions can wait longer to be seen in the ER, he said.
Boarding became such an issue in 2016 at the University of Mississippi Medical Center that it led them to develop a new system to deal with it, said Dr. Alan Jones, chairman of the Department of Emergency Medicine. Because it’s a large, 700-bed academic medical center with all the specialty services, it’s a natural referral center for hospitals that may not have a full complement of staff or specialty beds, he said.
While it accepts any patient who arrives by ambulance, it uses a communications center to track bed status at other area hospitals, he said. That allows facilities that are looking to transfer a patient to send them to the hospital that can best accommodate them, Jones said.
“We’re a trauma center and when we get a call to accept a trauma, we want to make sure we can do that, that we don’t have a pneumonia who can be treated at another center," he added. "It does help.”
While there are times when all the hospitals in the area have the same problem, it tends to be more of an issue at the larger facilities, Jones said.
“It’s a very common scenario around the U.S.,” he said.“The whole system is overtaxed.”
UMMC also deals with a shortage of nursing home beds, he said. And although the shortage of doctors and nurses is an issue in many places, there it’s less of a concern than the fact that hospitals in the area are closing for financial reasons, leaving those that remain to care for the displaced patients, he said.
“We’ve been fortunate that we’ve been able to keep our beds fully staffed,” he said. “We never stop hiring.”
Strategies to cope
St. Francis uses a variety of strategies to deal with the problem, Hoffman said.
Patients with complex medical issues are assigned case managers early in their stay who are tasked with discharge planning so when patients leave the hospital, they get the services they need, whether that’s a nursing home, rehab, supplies, equipment or home care, he said.
Also, the hospital encourages providers to see patients early in the day so those going home can be discharged to free up beds, he said.
“When the hospitals are full, we send notices to admitting physicians asking them to discharge patients,” he said, “(and) defer transfers from outlying hospitals.”
And as a last resort, Hoffman said, they divert ambulance traffic to other facilities — although that's a short-term fix because other ERs fill up too — or delay elective admissions and surgeries.
St. Francis regularly assesses its needs, a hospital spokeswoman said, and is in the process of relocating and expanding the ER at its downtown campus to more than double ER capacity.
Prisma, meanwhile, is investing in infrastructure, innovative care models and educational partnerships to deal with the situation, James said. For instance, ERs are being expanded at Greenville Memorial, Baptist Easley and Oconee Memorial, he said, and Greenville Memorial is redesigning how it operates to better manage the growing volume of seriously ill patients. Initiatives to reduce boarding include adding seven more private treatment rooms and another triage room as part of Greenville Memorial's new ER design, James said. The project will enhance the ability to evaluate and discharge patients quickly, he said, and could free up as many as 30 to 40 inpatient beds.
Prisma also is investing in increased primary care and community health programs to reduce the need for hospital care, such as opioid-treatment outreach and community-based paramedics, he added. And Baptist Easley has added social workers in the ER to identify what patients need and connect them with services, James said. It also continues to recruit nurses, he said.
Oconee Memorial, meanwhile, is scheduled to break ground this fall for its ER expansionto add 22 new private treatment rooms to its existing 20 beds and almost triple the department’s footprint from 8,400 square feet to about 22,000, he said.
The new ER, which will take about two years to complete, will include a fast-track unit for patients with less urgent issues and a unit for patients with more urgent or complicated issues, allowing everyone to be seen more quickly, James said.
Prisma is also working with academic partners like Clemson and the University of South Carolina to train more doctors, nurses and other providers, he said.
Spartanburg Regional Healthcare System also said via email that to address its growing volume of patients, it added a new pavilion with more than 50 beds at Spartanburg Medical Center in 2017 and acquired Mary Black Health System this year.
At AnMed Health in Anderson, Chief Nursing Officer Shaunda Trotter said there’s currently no problem with available beds.
“However, there are seasons in which that may occur,” she said via email. “When it does occur, we have processes in place to work through the seasonal challenge."
Looking to the future
All the long-term solutions to boarding, such as building new facilities and adding beds, cost a lot of money and often take years to accomplish, Hoffman said.
“Then (health care) costs go up and people are upset about that too,” Stanton said.
And because South Carolina is a Certificate of Need state, hospitals must apply for approval to add beds or buildings — a process that can take months or years and may be denied.
However, in Greenville, Pickens and Anderson counties, there are no pending applications to add general hospital beds, according to the state Department of Health and Environmental Control, and no applications for more beds have been denied in the last five years.
In an effort to address its needs, UMMC recently opened a 13-bed unit in an existing patient tower and has plans for another unit in the next year or so that will add 32 more beds, Jones said. But the new unit was full the day it opened, he said.
“We will probably need more than that in the next three to five years if we continue to see the same volume of patients,” Jones said. “It’s only going to intensify.”
Miller said that after her husband's collapse that Sunday, she saw the ER was packed. He was released the following Wednesday and has been improving ever since, she said. But it was an eye-opening experience.
“The quality of care is not the issue. There’s a bottleneck that does not allow for inpatient care ... and whether it’s because of no beds or no staff, it still becomes a crisis,” she said.
“Either we need to train more nurses or be building more hospitals,” she added. “But we need to get it fixed.”
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