A letter to the Biden administration co-authored last week by 33 medical groups, including the American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA), paints a devastating picture of the unfolding crisis that goes beyond the emergency services across the country. .
The letter was sent to President Joe Biden with a copy to Secretary Xavier Becerra of the Department of Health and Human Services and Secretary Alejandro Mayorkas of the US Department of Homeland Security.
The letter’s authors called for a summit of healthcare leaders to take urgent collective action to address the evolving crisis, in which “emergency services (EDs) have been brought to a point of rupture”.
The Biden administration did not respond to the nine-page letter. In the wake of the midterm elections, the continuation of the war in Ukraine and the pursuit of the interests of US imperialism remain at the forefront of the White House agenda. While his full attention is on foreign policy, all COVID pandemic mitigation measures have been lifted ahead of what is likely to be a devastating winter of illness and death.
After acknowledging the impact of the pandemic on the population and frontline healthcare workers, the letter begins by stating, “Our nation’s safety net is about to break beyond repair; Emergency departments are jammed and overwhelmed with patients waiting – waiting to be seen; awaiting admission to an inpatient bed in hospital; awaiting transfer to a psychiatric, skilled nursing or other specialized facility; or, simply waiting to return to their nursing home. And that breaking point is entirely beyond the control of the highly trained emergency physicians, nurses and other emergency room personnel who are doing their best to get everyone treated and alive.
As CAPE notes, the number of patients held in emergency departments awaiting care, also known as boarding schools, has reached crisis levels. The letter pointed out that staffing levels are dangerously low and wait times are worse now than at any other time during the pandemic. The Joint Commission defined boarding as “the practice of keeping patients in the emergency department or other temporary location after the decision to admit or transfer has been made”.
Current standards require boarding times not to exceed four hours, to avoid increased mortality and length of hospital stays. Violation of the ‘standard of care’ is a particular problem for poorer sections of the working class, especially those without health insurance or struggling to access their GPs.
CAPE wrote on its website: “Urgent care teams are being pushed to their limits. Demand for emergency care and services shows no signs of slowing as we head straight into this winter’s “triple threat” of influenza, COVID-19 and pediatric respiratory illnesses like RSV filling the emergency services. The influx of patients is only piling more stress on the shoulders of emergency doctors who are doing all they can to treat everyone in need.
As an anonymous emergency physician explained to CAPE, more than half of their facility’s emergency beds are occupied by resident patients. At one point, there were 35 residents in a 22-bed emergency department and an additional 20 patients in the waiting room. The average patient boarding time was 70 hours. that’s nearly three days, and the patient’s longest stay last month was over 200 hours.
The doctor added: “Additionally, we have patients who have unfortunately died in our waiting room while awaiting treatment. These deaths were entirely due to boarding. Our boarding numbers have unfortunately skyrocketed as a result of COVID due to increased surgical volumes and fewer inpatient nurses. Our tertiary care center is crippled with no end in sight.
Another wrote: ‘We are a 38 bed emergency department, usually with 30-40 patients in the waiting room and many EMS patients waiting for rooms in the hallway. Patients arrive agitated, acute psychotics, sometimes violent. We cannot provide these patients with quality medical care when they wait hours or even days for a bed. We also have critically ill patients requiring a higher level of care who must wait in the hallways. »
Emergency room doctors have been asked to attend to someone in the waiting room or even a patient’s car because there was no room to sit. Often their condition deteriorates rapidly, requiring emergency cardiopulmonary resuscitation. Sometimes, the individual was even found slumped over, having expired several hours before, without being noticed.
Last month, a charge nurse named Kelsay Irby made headlines by placing a 911 call from the emergency department (ED) at Saint Michael Medical Center in Silverdale, Wash., to Central Kitsap Fire and Rescue. She told firefighters that (emergency) personnel, “we’re drowning” patients. They had just five nurses to tend to 45 patients in their waiting room, many of whom suffered from heart and respiratory conditions. She was asking for help to help ED.
The nurse told the press: “I did not recognize the impact of what I was doing that night, and I was just working through a list of possible sources of help for my colleagues and, at the end of the matter, our patients.” According to the local press, the hospital employs around 180 contract workers but is seeking to fill around 300 positions. While an unconventional cry for help, the Silverdale case only serves to highlight by way of example the health care crisis and staffing shortages that affect every region of the country.
A study by Penn State and the University of California, San Francisco on the association between emergency department crowding and inpatient outcomes found that, on average, about 2.6% of hospitalized patients are died during their stay. When ER occupancy increased, the death rate of inpatients also increased. During peak ER occupancy, the inpatient death rate hit 5.4%, twice as high.
A critical report published last year in the New England Journal of Medicine(NEJM), titled “Emergency Department Overcrowding: The Canary in the Healthcare System,” said, “While often viewed as a mere inconvenience to patients, the impact of overcrowding emergency services on morbidity, mortality, medical errors, staff burnout and excessive cost is well documented but remains largely underestimated.
The authors of the report summarize their findings:
Often seen as a local problem in the ER, the cause of ER overcrowding is misaligned healthcare economics that drive hospitals to maintain high and inefficient inpatient count levels, often preferring high-margin patients. The resulting safeguard in emergency room admissions concentrates patient safety risks. Few efforts address the economic root cause of emergency department overcrowding.
The economic forces driving hospitals to restructure their operations also inevitably lead to high counts and overcrowded conditions in emergency departments due to “blocked access” or the inability to admit patients to hospital for definitive care.
The past two decades have seen a repeated process by which large health systems consolidate their operations through the process of mergers and acquisitions, a product of “market share and financial survival motivations,” as the report notes. The resulting overall capacity reductions (“efficiencies” generated by mergers) impact hospitals’ ability to handle surges in patient volumes and reduce overall care capacity.
The authors of the NEJM report note that “ER visits over the past two decades have greatly outpaced population growth. However, admissions increased by 21% during this period, while acute care hospitals and staffed beds decreased by 7% and 11%, respectively. The total number of emergency departments decreased and inpatient bed capacity decreased by 27%, from 3.32 to 2.41 per 1,000 population.
The impact of the pandemic on a shrinking healthcare system has been a massive attrition of healthcare personnel. Nearly 334,000 nurses, doctors and healthcare workers quit their jobs in 2021 due to heavy patient workloads, burnout and anxiety that their efforts won’t seem to stem the deluge of patients more and more sick who are pouring into the hospitals. These, in turn, leave a smaller pool of professionals with experience in the job market, further exacerbating the cycle of burnout.
In the letter to Biden, the healthcare organizations write, “While stress is a given in emergency medicine, the rate of burnout is extremely concerning and is causing additional strain on an already crippled healthcare system. Shift work, schedules, risk of exposure to infectious diseases, and violence in the emergency department can all affect the mental health and well-being of doctors and nurses. In addition to overcrowding and emergency room boarding, healthcare professionals now face stresses and moral injuries that go far beyond day-to-day practice.
Emergency departments were introduced into the healthcare infrastructure in the 1950s and 1960s to deal with acute medical conditions where early diagnosis and intervention can mean the difference between life and death. However, the crisis of capitalism and the financialization of the medical system have crippled the delivery of health care. Overcrowding in emergency departments and burnout of healthcare personnel are symptomatic of these processes. The warning in the letter to Biden only underscores the need for a socialist reorganization of health care so medical workers can once again do what they do best: save lives.
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