This commentary is by:
Ben Smith, MD — Medical Director, Emergency Department, Central Vermont Medical Center
Julie Vieth, MD — Medical Director, Emergency Department, University of Vermont Medical Center
Matthew Siket, MD — Emergency Physician, Medical Officer, Care Coordination System, University of Vermont Health Network
Ryan Sexton, MD — Medical Director, Emergency Department, Northeastern Vermont Regional Hospital, Immediate Past President, Vermont Medical Society
Right now, all across Vermont, too many patients requiring hospitalization are languishing in emergency departments (EDs), sometimes for days at a time. This is a phenomenon known as boarding, which is an unplanned delay in moving to the appropriate care setting because there is no available bed. For years, it has been a well-documented human rights catastrophe for mental health patients, and it has now grown to include those with medical illness, including the critically ill.
Boarding in an ED is data-proven to worsen outcomes. Every single person currently working in the ED has witnessed unacceptable, preventable outcomes caused by lack of hospital capacity. Vermonters are being hurt right now, and it should be considered a crisis. The American College of Emergency Physicians, in an open letter to President Biden, referred to boarding as a public health emergency. We agree. When patients do not move effectively out of the ED, our staff cannot provide the care our communities expect and deserve.
A few points are worth clarifying. First, boarding is a systems problem, not an ED problem. EDs don’t need advice on how to work harder, or better. Our staff are fiercely dedicated to caring for everyone who walks through their doors. They have shown up again and again, through four recent health care disasters: the Covid-19 pandemic, the ongoing opioid epidemic, the collapse of our mental health system, and generational socioeconomic decline. There is no work-from-home option. They face increasing violence, personal risk, and psychological trauma. They suffer the highest rates of burnout in the medical profession, and still, they show up. But despite the relentless courage and can-do attitude of those who work there, EDs are not bottomless wells of infinite capacity. They are simply not resourced to provide ongoing care for admitted patients — who belong on an inpatient unit — while simultaneously caring for all the new patients coming through their doors, with volumes increasing year over year.
Second, EDs are disproportionately used by vulnerable populations, including the unhoused, immigrant and refugee communities, and the elderly. These patients require more visits per capita, longer and more complex evaluations, and more frequent hospital admissions. When health policy fails to relieve ED boarding, it fails everyone needing acute care, but particularly our most vulnerable neighbors. To say it succinctly, our system, as currently structured, is overtly biased against the needs of the elderly and the vulnerable. It’s a health equity disaster, in real time.
Third, Vermont is uniquely vulnerable to the consequences of ED boarding. Vermont ranks fourth in two highly concerning statistics: 1) the percentage of citizens over age 65 and 2) the fewest acute care hospitals of any state.
Lastly, we need to dispense with the notion that the boarding crisis is a product of Covid-19, or surges of respiratory viruses. This phenomenon has proceeded throughout every season of the past two years, and has its roots in a deeply misguided austerity mindset toward health care labor that far precedes the pandemic. If our hospitals had adequate capacity, we could easily handle the predictable surge of admissions this winter. But they do not.
Why?
The answer is complex, but the single largest contributor is a lack of care options for those who require medical rehabilitation, long-term care, or home health. Every hospital in the state is caring for patients who could move to another setting if it were available. When those patients cannot leave, those beds are then unavailable for the acutely ill and injured, who arrive primarily through the ED. Boarding ensues, care is displaced into hallways and the waiting room, people increasingly go unseen after unreasonably long wait times, and emergencies go untreated. We desperately need an increase in skilled nursing and long-term care beds, home health supports, and robust, reliable funding mechanisms to support both.
In the context of this boarding crisis, we are deeply alarmed by the ongoing policy debate about reducing hospital beds. There is a dramatic disconnect between the prevalent perception of inefficiency and poor resource use and the reality of what is actually happening on the ground. We want to say clearly that a reduction of hospital beds will worsen the boarding crisis, displace patients from their home communities, and leave the most vulnerable patients without places to safely and reliably receive care.
In addition, the notion that we would close rural hospitals, or dramatically curtail what they can do, speaks to a mindset that prioritizes austerity over caring for our people. In a rural state, effective, decentralized care — where safe and appropriate — should be a core value. What’s more, many Vermonters struggle with transportation, and removing local care options will result in the disadvantaged receiving even less care than they do now. This is not the time to consolidate those resources – our system, and our people, simply cannot handle it.
Luckily, the policy environment in which we work is not fixed. It’s not some natural force beyond our power to affect. Vermont serves as a model to the nation for rural health care delivery, and we need to step up and lead by example. We desperately need our state and federal leaders to take this issue seriously, to correct the deep inadequacies of Medicare and Medicaid funding, and to find a way to dramatically increase supports for the elderly and the vulnerable. Vermonters are suffering, right now. They need help.
