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Throughout the pandemic, Emergency Departments (EDs) have been an essential gateway to medical care for COVID-19 patients. However, when COVID-19 surged, EDs became overrun. As hospital inpatient beds filled, a backlog of patients grew in the ED, admitted to the hospital but unable to be placed in an inpatient or observation unit (known as “boarding” patients in the ED). An example is a COVID-19-positive woman in Rhode Island who spent 10 hours with other infected patients in a small ED meeting room, waiting 36 hours after she arrived to be moved to an inpatient bed.

In addition to the obvious strain on patients, overcrowding and boarding in the ED can create significant problems for the operations of the hospital. The American College of Emergency Physicians has underscored that boarding “often results in…ambulance refusals, prolonged patient waiting times, and increased suffering for those who wait, lying on gurneys in Emergency Department corridors for hours, and even days, which affects not only their care and comfort but also the primary work of the Emergency Department staff taking care of Emergency Department patients.”

As the pandemic has worn on, those with other medical needs who delayed care during the COVID-19 surges are showing up in EDs. These patients are sicker than they might have been if they had received care months ago. Richard Zane, Professor and Chair of the Department of Emergency Medicine at the University of Colorado School of Medicine and Chief Innovation Officer at UCHealth in Aurora, Colorado, commented in a recent NEJM Catalyst article, “One of the consequences of this deferral of care is that people who would never have needed emergency care for diabetes now have uncontrolled diabetes. People who had mild strokes now have severe strokes. And people who had mild heart attacks now have severe heart attacks, and so on.”

All of this is taking a toll on ED staff and operations. In the aforementioned NEJM Catalyst article, which included a survey, respondents identified the top three problems facing EDs as: boarding patients, hiring and retaining quality staff, and clinician burnout. Journalist Dan Koeppel reported that through the pandemic, ED health professionals have experienced significant fear—“the fear of infecting their families, or that they themselves are infected and don’t know it yet. As doctors start to become sick with COVID-19—or have family members who get seriously ill or die—what was once professional becomes very personal.”

Why It Matters

One obvious result of ED crowding is that patients don’t receive the care that they need in a timely manner. This can have grave implications. A United Kingdom study showed that with even an 8- to 12-hour waiting time, the risk of death in the next 30 days increased by 10%. In pandemic times, ED crowding greatly increases the risk of COVID-free patients contracting the virus from others as they wait.

Another implication is that health professionals who work in the ER—having chosen one of the most unpredictable, chaotic, and in some cases, traumatic environments in which to practice—are experiencing an exaggerated level of stress. This will not be sustainable for some, and with the current staffing shortage (nurses, physicians, and other health professionals), losing any clinicians to burnout will further debilitate EDs.

In the book Every Minute Is a Day, aforementioned journalist Dan Koeppel recorded a text exchange with his cousin, an ED physician. When he asked his cousin “How are you doing? I’m worried for you,” he received the response, “hanging by a thread.” When he asked where his cousin was on a scale of 1 to 10, 10 being the most severe state, his cousin replied “100.”

Even as the pandemic begins to subside in parts of the U.S., the mark it has made on EDs and their staff will be difficult to repair. New processes, protocols, and technologies will need to be developed to help EDs and ED staff function to the best of their abilities, even and especially during times of pandemic surge and crisis.

One positive outcome of the pandemic in EDs, which may appear counterintuitive, is that the volume of behavioral/mental health patients has increased. While this may in part be a result of increasing prevalence of behavioral health issues, the need has always existed but now has become “normalized.” That translates into a larger burden on EDs but also into more people who really need care now seeking the help they need.

Related Links

NEJM Catalyst

The Hardest Time in the History of Emergency Medicine


An Emergency Room Doctor’s View of the COVID Crisis

American College of Emergency Physicians

Inside a Rhode Island Hospital E.R. Overwhelmed by Omicron

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