The Washington PostDemocracy Dies in Darkness

Patient safety top concern as emergency rooms fill up

The Emergency Medicine entrance at the George Washington University Hospital on Dec. 21. (Craig Hudson for The Washington Post)
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A winter surge in coronavirus cases and an uptick in acutely sick patients is overwhelming hospitals across the region and nation, leading to long wait times that emergency medicine experts and first responders say threaten patient safety.

First responders monitoring Maryland’s hospitals for signs they might need to divert patients from busy emergency rooms saw their dashboards light up in recent weeks. When inpatient hospital beds fill up, emergency departments have no place to send patients who must be admitted to the main hospital for further care, leaving them stuck as others languish in waiting rooms.

“An underappreciated and underreported aspect of this, nationally, is people are dying because we cannot get to them fast enough. If you wait for a long time in the waiting room, your situation is going to deteriorate and you have a much high chance of morbidity and catastrophic events,” said Gabe Kelen, chair of the Department of Emergency Medicine at Johns Hopkins University.

President Biden on Tuesday announced plans to dispatch medical teams to hospitals in the Midwest and Northeast that can’t keep up with the demand, but D.C., Maryland and Virginia are not on the list. Maryland Gov. Larry Hogan (R) on Tuesday committed $50 million to help hospitals struggling with staffing.

Health workers who shouldered the risk of coronavirus transmission amid shortages of protective equipment before vaccines were available are still straining to meet high volumes and are exhausted, hospital and health-care officials said.

Kelen, a 40-year veteran of emergency medicine and American College of Emergency Physicians board member, co-authored a paper titled “Emergency Department Crowding: The Canary in the Health Care System” in the New England Journal of Medicine in September.

Before the pandemic, more than 90 percent of U.S. emergency departments already “found themselves stressed beyond the breaking point at least some of the time,” the authors concluded.

Now patients in Maryland and across the country are waiting 12, 18 or up to 24 hours in the emergency department for care, he said Monday evening, after working a shift at Johns Hopkins Hospital in Baltimore.

“It’s not unusual to have twice as many patients in your emergency department as there are beds in the emergency department because they’re in the waiting room,” Kelen said, adding that coronavirus infection protocols slow everything down.

He worries about the people who avoid calling an ambulance out of fear of contracting the coronavirus, that there will be fewer ambulances available because they are waiting to offload patients, that people can’t get primary, specialty and follow-up appointments for weeks and months, and that others will put off semi-urgent or urgent surgery for cancer, for example.

“There’s like 10 different ways people are getting harmed by this pandemic,” Kelen said.

Throughout 2020, aside from the many and severe covid-19 cases, emergency departments saw fewer patients as people avoided leaving their homes. Some hospitals cut employees’ hours. As vaccines became available and society began to reopen, people rescheduled appointments. Some of those who deferred care were sick enough to have no choice but to go the emergency room, compounded by the usual increase in respiratory illness in the winter as well as the delta variant, and now omicron.

The latest data on waiting room times and numbers of patients coming to the emergency room doesn’t yet reflect the current surge, according to statewide associations representing Virginia and Maryland hospitals and national doctors organizations.

Record weekly infection rates were reported this week in Maryland and D.C. as case counts in Virginia also mushroomed. In the District, Mayor Muriel E. Bowser (D) has instituted vaccine requirements in restaurants, bars and gyms; reinstated the mask mandate and stocked libraries with free antigen tests, which were met with long lines.

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In D.C., 10 ambulances were out of service at times Saturday because of a rapid rise in positive coronavirus tests among emergency medical personnel and also a switch to manual scheduling because of an outage in the electric system used by the DC Fire & Emergency Medical Services Department. A private provider and additional staff filled any gaps, said department spokeswoman Jennifer Donelan.

In Maryland, the number of hours that all hospitals were on alert and diverting patients increased by about 4,000 hours to 36,563 hours from Nov. 21 to Dec. 21, compared with the previous surge from Aug. 21 to Sept. 21, according to data compiled by the Maryland Hospital Association.

The time patients who arrive by ambulance wait in hallways or other ancillary spaces — paramedics and EMTs by their side — for a bed to open up is also on the rise, emergency medical officials said.

“It means someone who needs EMS waits longer for an ambulance to arrive in general. That difference could be trivial or it could be life affecting. It just depends on the patient’s condition and where he or she is,” said Ted Delbridge, executive director of the Maryland Institute for Emergency Medical Service Systems (MIEMSS).

The pandemic exacerbated an existing problem, experts said, leading the Montgomery County Fire and Rescue Service to rely on programs designed to keep low-priority patients out of crowded emergency rooms. If patients meet certain criteria, first responders can arrange an immediate telemedicine visit, bring them to an urgent care or drop them in the waiting room with walk-in patients.

Maryland health officials on Tuesday directed hospitals to reduce scheduling non-urgent surgeries that would require an overnight stay when the total number of covid-19 hospitalizations reached 1,200, a threshold met the next day, according to state data.

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In extreme situations, paramedics and EMTs have waited three to four hours in some parts of the state, said Ben Kaufman, battalion chief at the Montgomery County Fire and Rescue Service. On average the department’s first responders turn around patients in 25 minutes or less, but over the past four months calls have sometimes stretched to 45 minutes, causing alarm, although the county has enough staff and equipment to accommodate the increase in the short term, he said.

“The take home message is it’s not one thing. covid is a factor. If we experience a surge the way we did in 2020 … it’s going to be even harder for the hospitals to keep up,” he said.

Joel Buzy, who was a firefighter-paramedic for 20 years before he became a physician in the emergency department at Adventist HealthCare Shady Grove Medical Center, said although Montgomery County is flush with ambulances and resources, the wait times are troubling.

“It pains me to hear those times,” he said in a county training video with Kaufman. “One, for the patient of course, sitting on the cot in the hallway waiting for a bed. Two, for the crew that’s waiting. Three, for the system. I live in Montgomery County. If my family or anyone else in this county needs an ambulance, I want that ambulance to be available.”

His hospital and others have added observation units near the emergency department and the state reopened the old Washington Adventist Hospital in Takoma Park for coronavirus patients to relieve the pressure somewhat.

At 6 a.m. in the calm of the emergency department before the crescendo of patients builds, Buzy said, he reminds the nursing staff they have been there for their community through all the highs and lows and calls them heroes.

“But it’s been a strain, no question,” he said. “The question is now long is this going to last and we don’t have an answer for that. It can be scary. But we still show up every day.”

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