Hospitals strive to reduce waiting lines for beds

Many Massachusetts hospitals, particularly academic medical centers, are so full during the week that patients can wait 10 or more hours in emergency room beds before getting a room and a regular bed.

Public health officials, hospital executives, and doctors are increasingly concerned about emergency department ''boarding," because of the potential impact on both patient safety and staff burnout. The Joint Commission on Accreditation of Healthcare Organizations, which accredits US hospitals, this year added to its other evaluations whether hospitals reduce waits in overflow areas.

In January, the Massachusetts Department of Public Health took a more dramatic step. To get patients a bit closer to specialized caregivers, it adopted a policy allowing hospitals to park waiting patients in hallways on regular inpatient floors, as long as they don't block fire exits or pedestrian traffic. The department soon plans to begin monitoring on a state website the numbers of patients waiting for rooms. Health officials could force hospitals to cancel elective surgeries, a step the department has never taken, if waits get too long.

''Last winter and this winter, we've experienced levels of peak demand where there are very few beds and people boarding in the emergency departments," said Paul Dreyer, director of the department's Division of Health Care Quality.

Typical is the situation recently at Massachusetts General Hospital. Surrounded by patients on gurneys in an emergency room corridor, Dr. Alasdair Conn pointed to a color-coded chart on a large computer screen. ''This is my heartburn," he said.

It was 1:30 p.m. on Thursday, and 20 patients in Mass. General's emergency department needed to be admitted to the hospital for more extensive care. But the hospital had beds for only eight new patients. The electronic chart listed how long patients had been waiting for beds on a medical floor. The longest: two patients for 21 hours and one patient for 22 hours. A half-dozen recent arrivals were parked temporarily in hallways.

''When it's like this for hours on end, it takes a toll on nurses, staff, even people who clean the rooms," said Conn. ''I can't imagine how infuriating it is for someone who is sick to come here and wait."

Executives and doctors can't explain exactly why their hospitals are so full, but they have theories. From the mid-1970s to the mid-1990s, the numbers of patients checking into hospitals declined and so did hospital occupancy rates, Dreyer said. By the 1990s, many healthcare specialists predicted that managed care insurance companies would restrict overnight hospital stays well into the future. So, hospitals mothballed beds, and some shut down entirely. By 2001, the number of acute-care hospitals in Massachusetts had fallen 27 percent over a decade, to 68.

Nonetheless, patient demand has climbed steadily, fueled by a growing number of medical procedures and tests, many of which are less invasive than previous treatments and can be used to treat an expanding pool of older and sicker patients.

While patient discharges jumped 5.3 percent at the state's teaching hospitals and 3.5 percent at community hospitals between 2002 and 2003, the number of patients grew just 2.3 percent at community hospitals from 2003 to 2004 and stayed flat at teaching hospitals. Some teaching hospital executives say that's because they're full.

''The demand for care here seems to be unabated and we only have so much capacity," said Dr. F. Richard Bringhurst, senior vice president of medicine and research management at Mass. General, which treated 48,609 overnight patients and 1.62 million outpatients last year.

Research on whether long emergency room waits harm patients and contribute to staff burnout is limited. But doctors and healthcare specialists intuitively believe emergency department boarding can hurt care, particularly as medicine has become more specialized.

''I don't think one has to do research to know the E. D. is not going to have the depth of expertise," said Dr. Robert Wise, a vice president at the Joint Commission. ''They're very busy. They're about diagnosis and triage."

As a result, hospitals are searching for ways to reduce waits.

Some, including Children's Hospital, Brigham and Women's Hospital, and Beth Israel Deaconess Medical Center, are spending millions of dollars to add beds.

To make patients waiting in the emergency department more comfortable, Beth Israel last year started serving meals and providing physical therapy to patients waiting for an inpatient bed, which averages 10 hours from the time they arrive at the emergency room. It is hard to compare hospital waits, because hospitals often measure them differently, but Mass. General says its average wait for a bed on a hospital floor is 10 hours from the time the emergency department requests a bed.

Boston Medical Center reduced its average wait for a hospital bed to three hours from four, partly by using an innovative strategy created by Eugene Litvak, a professor of healthcare and operations management at Boston University. Litvak believes emergency department waits are caused by poor planning, and he is analyzing Beth Israel Deaconess's situation. Boston Medical Center required surgeons to distribute their operations more evenly over the week, more predictably freeing up beds for emergency department admissions. Still, the hospital is full and adding beds.

Mass. General is one hospital that has taken the brunt of patient overcrowding, because of its reputation for quality care, the large number of surgical specialists competing for beds, and because many Massachusetts hospitals that closed were nearby.

Last year, the hospital's emergency department began assigning nurses to staff corridors. Joan Higgins, who lives nearby in Boston, was reading a book on a gurney as her son read in a chair nearby. She'd been there more than two hours and was waiting for a blood test to determine if she'd go home or be admitted.

''We would probably go somewhere else if the wait is 10 hours," she said. But then she noted a problem: Her records are at Mass. General.

Bringhurst said a hospital committee on capacity hopes new strategies will make a difference. For example, overnight patients who can't be discharged because they're waiting for one or two tests are now discharged and given priority for the tests as outpatients, freeing up their beds sooner. Groups of doctors and residents now are making their rounds to patients twice a day, rather than once, also leading to earlier discharges.

He said the committee also will talk to some surgeons about changing the days they operate, so the hospital can more evenly distribute beds for surgery patients during the week. ''The most difficult part of this challenge is changing human behavior and changing habits," Bringhurst said.

Liz Kowalczyk can be reached at kowalczyk@globe.com.