By Liese Klein
The Middletown Press
Jun. 22 鈥� It鈥檚 not the number of people in the hospital鈥檚 waiting room 鈥� it鈥檚 the logjam in the hallways and the patients stuck in beds upstairs waiting for a transfer to rehab or a nursing home.
鈥淚t鈥檚 bad for patient care, just on its face ... somebody sitting in a hallway for three days under fluorescent lights,鈥� said Dr. Chris Moore.
Moore highlighted Connecticut鈥檚 growing problem with 鈥渂oarding,鈥� when patients who are admitted after initial care in an emergency room have to wait for beds elsewhere in the hospital for longer than four hours.
Although detailed data on the extent of the boarding problem in Connecticut hospitals has not been available until this year, emergency department experts say wait times are getting longer and patient care is being impacted more and more every year, especially in larger urban, academic and safety-net hospitals.
鈥淚t鈥檚 getting worse,鈥� Moore said. 鈥淚t鈥檚 a very big public health issue that will affect people and their family members in the state... It also impacts our ability to care for other patients effectively.鈥�
An emergency doctor at Yale New Haven Hospital , Moore was one of a group of experts who authored a report on the issue of emergency room boarding that was presented to state officials late last year. That report 鈥� which for the first time gathered the most recent data on the boarding issue at 28 of Connecticut鈥檚 hospitals 鈥� sparked its first action earlier this month with the addition to the state budget of a change that would speed transfers out of acute-care hospitals to rehab and other facilities.
鈥淚t鈥檚 really easier to keep the status quo in a lot of ways, but it鈥檚 not the right thing for the patient,鈥� Moore said. 鈥淚t鈥檚 my hope that public visibility will help this.鈥�
HBO show highlights growing issue
Crowding in emergency rooms has traditionally been understood as jammed waiting rooms, full of patients waiting for care after walking in with all levels of illnesses and injuries.
But a storyline on popular HBO drama 鈥淭he Pitt鈥� illustrated the modern iteration of that crowding: Hospital-wide backups in moving patients from one level of care to another that extend to delays in moving patients out of the hospital when they get better.
鈥淥ur department is mostly clogged with boarders. Those are admitted patients waiting for a room upstairs, sometimes for days,鈥� series star Noah Wyle tells a group of young doctors in the first 10 minutes of the show鈥檚 premiere episode. The impact of boarding in emergency rooms also leads to one of the show鈥檚 most disturbing scenes: An enraged patient punches a nurse after being kept waiting for hours to see a doctor.
Health care experts and doctors have enthusiastically endorsed the HBO show鈥檚 depiction of boarding, and Wyle has become a lobbyist on health care issues and is scheduled to appear at a national meeting of the American College of Emergency Physicians in September. Even so, the problem is much bigger than a single hospital, Moore said.
鈥淚 think many people are very familiar with crowded emergency departments or being in hallways, but I think it鈥檚 harder to view it systemically and understand that it really is systemic,鈥� Moore said. 鈥淚t does take time for people to really realize what鈥檚 going on and how it鈥檚 happening.鈥�
Data highlights Connecticut ED crowding
Action on addressing boarding has been stalled in part due to a lack of specific data on the extent of the problem, Moore said. In Connecticut, neither the Department of Public Health nor the Office of Health Strategy has consistently collected data on the extent of boarding in the state鈥檚 hospitals.
After an initial report from Moore鈥檚 working group, the state legislature passed a law in May 2024 requiring hospitals to compile and share key boarding metrics, including the percentage of admitted patients who had to wait more than four hours for an available bed.
The Connecticut Hospital Association compiled the data and put out its own report in February that emphasized the multiple factors contributing to boarding at hospitals statewide. Nearly 1.7 million people visited Connecticut hospital emergency rooms in 2024, with 13.7% of them being admitted for additional care.
Adding to crowding, the volume of patients under 鈥渙bservation,鈥� or being evaluated medically while in an emergency room, accounted for 9% of volume, a number that has increased by 30% since 2021, according to the CHA.
鈥淗ospitals continue to be challenged to balance the influx of new patients with the continuing care and management of those already there,鈥� the report stated.
After surging to record highs nationally in 2022, boarding rates fell in 2023 but remained elevated at high-volume emergency departments, according to a study cited in Becker鈥檚 Hospital Review.
Boarding rates diverge across CT hospital systems
The new batch of stats for Connecticut reflects the complexity of the problem 鈥� hospitals vary widely on their boarding percentages, even within the same health system.
For example, Hartford HealthCare鈥檚 Hartford Hospital had the highest emergency department boarding percentage in the state, at 63.1%, while St. Vincent鈥檚 Medical Center in Bridgeport, part of the same system, had among the lowest, at 21.5%. At Yale New Haven Health, Greenwich Hospital has the lowest boarding percentage, at 13.6%, while Yale New Haven Hospital has the highest, at 46.7%.
The metric is defined by state law as the percentage of patients 鈥渨ho were admitted after presenting to the ED but were transferred to an available bed located in a physical location other than the ED more than four hours after an admitting order for the patient was completed.鈥� The average boarding percentage at all 28 hospitals in Connecticut was 38.7%, with patients waiting an average of 5 hours and 45 minutes to be admitted after first showing up at the emergency room.
A 鈥減erfect storm of variables鈥� can come together to boost an individual hospital鈥檚 boarding percentage, said Marci Mitchell, senior director of the hospital association鈥檚 ChimeData Solutions program, which helped compile the report. Large urban and academic hospitals tend to treat sicker patients due to sicker local populations. The ability to offer specialized care also draws sicker patients to core hospitals from around the region, she said.
鈥淭hose hospitals that have more acute patients or higher-acuity patients are going to have (higher boarding) just because they鈥檙e dealing with more complex patients,鈥� Mitchell said.
The COVID-19 pandemic worsened the issues around emergency-department boarding across the state, Mitchell said, leading to lower staffing levels and patients with more serious ailments who are more likely to defer care.
鈥淲e鈥檙e seeing sicker patients that need more care than before COVID,鈥� Mitchell said. 鈥淲e鈥檙e also seeing access issues,鈥� she added, a problem likely to get worse if promised cuts to Medicaid and other federal safety-net programs are enacted.
Connecticut鈥檚 emergency department boarding involves more Medicare patients than the national average, likely due to the state鈥檚 aging population, Mitchell said. The data also indicates there is a higher proportion of patients who need mental health care amid a shortage of beds, leading to longer boarding stays awaiting care.
A 鈥減andemic鈥� of mental health problems has contributed to ER crowding nationwide, said Dr. Mahshid Abir , an author of an April report by the RAND research organization on challenges facing emergency care in the U.S.
鈥淚 call it a pandemic deliberately,鈥� Abir said. "(It) started before the COVID-19 pandemic, increased in severity and intensity during the pandemic, and, frankly, I鈥檓 not even sure that it鈥檚 plateaued yet.鈥�
The surge in patients with complex mental health and chronic conditions have fueled high rates of burnout in ER staff amid challenges to funding for emergency care, Abir said.
鈥淭he biggest message from our report is really the fact that this is not sustainable,鈥� Abir said. 鈥淭his safety net in the United States, people take it for granted ... . We need policies at local, state and federal levels to really address many of the challenges, and also to help sustain the values that ERs provide to their communities.鈥�
Demand for emergency care outpaces supply
In some ways, the crowds at emergency rooms reflect the successes of U.S. medicine, in that more people are surviving once-fatal ailments like cancer, stroke and heart attack but needing more care as they live with chronic conditions, said Dr. Arjun Venkatesh, chair of the Department of Emergency Medicine at Yale University.
鈥淧eople are not only living longer, but they鈥檙e living longer with more and more complexity and morbidity of illness,鈥� Venkatesh said. 鈥淲hat鈥檚 happened is that over the last 20 years, there鈥檚 a tremendous increase in the need for acute hospital care.鈥�
Even as more people need care, the number of emergency treatment sites in most states has remained the same or even gone down, Venkatesh said. 鈥淭he capacity, the demand for acute hospital care exceeds the supply.鈥�
Meeting the need for emergency care is not as simple as speeding treatment in the emergency room or shuffling patients through the hospital faster.
One factor is that fewer nursing-home and rehab beds mean the sickest patients stay longer in acute-care hospitals 鈥� sometimes up to a year. Care has also gotten more complex, with modern treatments requiring more technology, multiple specialists and longer hospital stays.
In addition, Connecticut, like most of the Northeast, has also not built enough new hospitals to meet the demands of an aging population, Venkatesh said.
鈥淭here鈥檚 not like a single magic bullet that鈥檒l solve it, and it requires fixing a lot of the broken parts of our health care system,鈥� Venkatesh said. 鈥淚n many ways, when you see a patient in the emergency department waiting for care, it鈥檚 really just emblematic of a broken system outside of that hospital.鈥�
Yale 鈥榚ngineers鈥� shorter wait times
At Yale New Haven Health, managers have focused on ensuring that no one opts out of emergency care due to wait times: The system鈥檚 鈥渓eft without being seen鈥� rate for its hospital emergency departments is 1%, well below the national average of 4%.
鈥淲hat we鈥檝e done is we鈥檝e basically tried to engineer the best amount of access to care we can despite the challenging circumstances,鈥� Venkatesh said. Yale New Haven Health has built new units in some hospital waiting rooms to quickly assess arriving patients and get a jump on ordering tests and scans.
At Yale New Haven Hospital 鈥� which operates two campuses with emergency departments in separate areas of New Haven 鈥� administrators work with ambulance companies to ensure that patients are transported to the appropriate campus with capacity.
The system has also explored the use of artificial intelligence tools to more quickly assess patients and speed necessary care.
鈥淲e do a lot of systems engineering work to improve the flow of patients through the emergency department,鈥� Venkatesh said.
On the statewide level, a proposal based on a bill addressing ER overcrowding was included in the budget, speeding the process of appointing conservators to approve hospital care for patients unable to consent. In advocating for the proposal, the Connecticut Hospital Association linked the issue to backups in the health care system.
鈥淐hallenges relating to the performance of conservators have been highlighted in two recent reports as a cause of emergency department boarding and crowding and as an impediment to achieving timely and effective discharge of patients from hospitals,鈥� the CHA said.
On the level of individual patients, emergency care experts hope that the public will have a little patience with the systemic issues around the boarding problem the next time they encounter a wait for care or a hospital bed.
鈥淚n a health care system where it鈥檚 hard to get an appointment, it鈥檚 hard to get in and seen, and a lot of care gets often delayed or deferred ... the emergency department still remains the only open door,鈥� Venkatesh said. 鈥淲ith a system that is overwhelmed, we鈥檙e trying to do the best we can. A little bit of grace for the teams goes a long way.鈥�
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