Howard Forman (@thehowie) is a professor of radiology, economics, public health and management at Yale University.
Just after World War II, there were 1.4 million hospital beds available in the U.S. The most recent estimates show fewer than 900,000 beds, even though the nation’s population has grown by 120% over the same period. Better care delivery, technology, and changing financial incentives have driven much of this decrease, with hospitals continuing to downsize their staff and operations, making for less-flexible bed management. Also shrinking in number are emergency rooms (ERs), even while demand increases.
The ER has become the de facto multi-specialty clinic of the 21st century. The modern ER no longer just serves as the place for sewing up wounds or triaging patients for more acute care. Delivery of screening, diagnostic, and therapeutic services occur in and around the ER, resulting in huge improvements in stroke, cardiac and trauma outcomes.
In addition to the expansion of services, the ER has also become the medical provider of last resort in most communities: serving insured patients when their private physicians are unavailable and underinsured or uninsured patients. This usage has led to a significant increase in demand for ER space. Most ERs report crowding at some point during the day, and, increasingly, wait times and lengths of stay are the preferred metrics in evaluating ER quality of care.
In the past few decades, an additional burden has been placed on the ER with major implications for patient care: boarding. Boarding occurs when a patient lingers on a stretcher in the ER, and often the hallway, despite having been admitted to the hospital. Often when a patient is boarded, there are no hospital beds available upstairs.