ER Hallway Beds: A Crisis for Patients and Staff | STAT News
Cara M. Squints against the harsh fluorescent lights, a blanket clutched to her chest, a vomit bag close at hand. She describes her migraine not as a headache, but as an ice pick stabbing through her right eye. At home, the glow of a laptop screen triggered waves of nausea; birdsong felt like hammering spikes. For most of an emergency physician’s career, a patient like Cara M. Would be examined in a low-lighted, relatively quiet room. Not in today’s increasingly strained version of healthcare.
She’s parked on a gurney along a brightly lit, busy hallway, one in a long line of patients awaiting care. Darkness is achieved with a blanket pulled over her eyes, but it offers little respite from overhead announcements blaring from a ceiling speaker. The noise forces a pause in conversation, a squeezing of ears. “What are we doing here?” is the unspoken question hanging in the air, a sentiment shared by many, including the physician attempting to assess her. A room number is taped to the wall above her gurney, a marker of her assigned space, yet without these makeshift beds, patients would be facing hours-long waits in the crowded ER waiting room.
The Rising Tide of ER Boarding
Emergency department (ED) boarding – the practice of holding patients in the ED while awaiting an inpatient hospital bed – is a pervasive and worsening national crisis. As patients spend longer in the ED, the availability of beds for latest arrivals dwindles. This burden falls heavily on ER staff, who are forced to convert any available space – hallways, corners – into makeshift treatment areas. Physically, it means transforming non-clinical spaces into care zones; emotionally and ethically, it forces staff to question and compromise their standards of care. The trade-off for timely access becomes enduring conditions that may worsen a patient’s health, while for staff, it’s a shift in practice patterns that can erode professional fulfillment.
Hallway beds have long served as a short-term fix for ED crowding, but the emergency department can no longer function as both the community’s safety net and the hospital’s pressure valve. ER visits in the United States have steadily increased, from 128.97 million in 2010 to 155.4 million in 2022. Simultaneously, hospitals grapple with rising occupancy rates, fewer available beds, and an influx of increasingly ill patients presenting with complex medical, mental health, and social issues. There’s a critical lack of support for the safety net itself.
The Crumbling Foundation of Primary Care
Cara M. Actively avoided the ER, but an appointment with her primary care physician wasn’t available for three weeks. This highlights a critical issue: the crumbling foundation of primary care. High workloads, bureaucratic obstacles, poor reimbursement rates, and burnout are driving dedicated providers away. Those who remain face guidelines so demanding that meeting them all would require more than 24 hours in a day. When Cara M.’s headache intensified and she couldn’t keep down her medication, her overbooked physician group, like many practices, directed her to the ER. This illustrates a concerning trend: primary care’s inability to absorb patient needs, pushing them towards more expensive and often less appropriate emergency care.
The situation is further complicated by a growing shortage of primary care clinicians. Nearly one-third of Americans don’t have ready access to a primary care doctor, and increasing numbers of adults and children require management of chronic diseases. This lack of access exacerbates the strain on emergency departments, turning them into default primary care providers for many.
The Ethical and Clinical Costs
Responding to unexpected challenges is inherent to emergency medicine. However, as crowding and hallway beds turn into the norm, they chip away at the core tenets of the profession, eroding the moral compass and high standards that sustain emergency medicine staff. The practice demands a constant negotiation between providing the best possible care and the limitations of the environment.
The consequences extend beyond logistical challenges. Patients in hallway beds report lower satisfaction with their care and are at greater risk for diagnostic errors and suboptimal history taking, particularly when discussing sensitive issues like suicidal ideation, domestic violence, or elder abuse. Electronic monitoring and nursing attention are as well compromised in these settings. Research suggests that triage decisions may be influenced by a patient’s insurance status, with those on Medicaid or without insurance potentially facing longer waits and less favorable placement.
The impact on clinicians is equally profound. The constant pressure and compromised conditions contribute to moral distress and burnout. One physician shared a personal experience of having to deliver a hard cancer diagnosis to a patient in a crowded hallway, acutely aware of the lack of privacy and dignity. The experience highlighted the ethical dilemma of balancing the need for thorough examination with the constraints of the environment, leading to a potentially missed diagnosis in another case due to the inability to fully assess a patient’s condition without compromising their privacy.
Beyond Band-Aids: Addressing the Systemic Issues
While hallway beds may seem like a necessary evil, they are not a sustainable solution. The emergency department cannot continue to absorb the failures of other parts of the healthcare system. Addressing this crisis requires a multi-faceted approach, including strengthening primary care, improving access to mental health services, and addressing social determinants of health.
One potential step is to re-evaluate how we measure success in emergency departments. Current metrics often prioritize speed and efficiency, potentially incentivizing shortcuts that compromise quality of care. A shift towards valuing patient experience, thoroughness of assessment, and ethical considerations could help to restore the focus on what truly matters.
hospitals need to invest in strategies to improve patient flow and reduce boarding times. This could include implementing dedicated observation units, streamlining discharge processes, and collaborating with community partners to provide alternative care options for patients who don’t require acute hospital admission.
What Comes Next: A Call for Systemic Change
The situation demands a fundamental rethinking of how healthcare is delivered. It requires a commitment from policymakers, healthcare leaders, and clinicians to prioritize patient-centered care, invest in primary care, and address the systemic issues that are driving patients to the emergency department in the first place.
For now, the focus must be on mitigating the harm caused by hallway beds. This includes providing patients with basic comforts like blankets and pillows, ensuring privacy as much as possible, and prioritizing clear communication. But these are merely stopgap measures. The ultimate goal must be to create a healthcare system where hallway beds are no longer necessary, and every patient receives the care they deserve in a safe, dignified, and timely manner.
Jay Baruch, M.D., is professor of emergency medicine and director of the Medical Humanities and Bioethics Scholarly Concentration at the Warren Alpert Medical School of Brown University in Providence, R.I. His latest book is “Tornado of Life: A Doctor’s Journey through Constraints and Creativity in the ER” (MIT Press). The patients’ names and identifying details have been changed.