Admin & Clinical Operations ED Hallway Beds: The Patient Experience Drawbacks, and Potential Solutions

ED Hallway Beds: The Patient Experience, Drawbacks, and Potential Solutions

By Derrick Huang, MD; Meagan Hunt, MD; Tehreem Rehman, MD, MPH; Max Kravitz, MD, MBA; and Megan Davis, MD, MBA, on behalf of the SAEM ED Administration and Clinical Operations Committee

Emergency department (ED) overcrowding is becoming more prevalent across the nation. This problem occurs when the demand for patient care in the ED exceeds the number of bays or rooms in which the emergency medicine team can provide care. Unsurprisingly, overcrowding has been associated with worse health outcomes, decreased patient satisfaction, and physician burnout. Indeed, when the patient volume in the ED exceeds room capacity, patients may need be seen in hallway beds as opposed to private rooms. Unfortunately, institutional failures to address inpatient boarding in our EDs create a visible inequity in care for our patients. Is it any surprise that patients ask, “Why am I being the one seen in the hallway?”

The Benefits of Hallway Beds

Why would EDs resort to care in hallway beds when such an approach can negatively impact the satisfaction of care for patients and their families? The simple answer is that hallway spaces add capacity and one of the biggest drivers of patient satisfaction is wait time. Increasing capacity with hallway beds decreases the time a patient must wait to be seen. Hallway beds are also dynamic, simple to operationalize, and free to implement. They allow departments to “flex up” as needed during busier days and times. This impermanent solution comes at no cost to our hospitals and can be employed immediately by ED care teams desperate to care for more patients. Most importantly, this allows ED teams to decompress lower acuity patients quickly to reduce overcrowding in swelling lobbies as quickly as possible when a volume surge occurs.

The Drawbacks

Unfortunately, patient care in hallway beds is associated with worse health outcomes. Care in the hallway goes beyond its strong association with prolonged length of stay and dissatisfaction from both patients and staff. Outside of a private room, hallway patients do not have access to the same level of electronic monitoring. The bedside nurse may be providing care that exceeds his or her usual patient load. While lower acuity patients can be managed in this scenario without safety concerns in many cases, the patient experience is that he or she is the lowest priority in the nurse’s assignment and often in their provider’s work list.

The hallway patient observes more acute patients receiving treatment while they remain waiting; they often report feeling that the care they do finally receive, is rushed. This can leave the patient feeling that his or her concerns are dismissed and not adequately addressed.

While the ED team is compelled to be highly aware of the acuity and emergent priority of its panel of patients, this is certainly not transparent to the layperson. Our patients come to us feeling very vulnerable, scared, and worried about their symptoms being a life-threatening emergency. Although hallway beds theoretically allow the patient to reach a treatment space more rapidly, the patient may experience inequity in the response time of staff, decreased time spent at the bedside compared to time spent with other patients in other ED spaces, and a complete lack of privacy for their evaluation.

Unsurprisingly, the low priority status of the hallway patient and the limitations of hallway evaluation can result in unrecognized clinical deterioration. Hallway patients have been found unstable, apneic, unconscious, and in a state of shock [1]. Coordination of care and communication among the ED, admitting, and consulting teams — not to mention patient family members — can be difficult to maintain. Derelict Intravenous lines, delays in medication administration, exposure to traumatic psychological events, and inadequate pain treatment follow naturally. These consequences are likely multifactorial and can also be partially explained as a consequene of inadequate resources and staffing.

Socioeconomic Bias

The decision involved in placing a patient in a hallway bed as opposed to a private room also brings up the concern of socioeconomic and ethnic bias in placement. This problem may be amplified by the decision to place patients who are undifferentiated and not triaged appropriately especially during busier ED hours. Prior studies have shown evidence of ethnic and racial bias, gender bias, and age biases in the often-chaotic environment of the ED. Indeed, evidence of bias in treatment by ethnicity and race have played a part in establishing policies toward pain management in the ED. Biases likely play a role in bed placement as well. For instance, in a large, retrospective study conducted by Kim et al. at two academic EDs from 2013–2016, race was not found to be an independent predictor for hallway bed assignment, whereas visits paid primarily by Medicaid were found to have a disproportionate association with hallway bed assignment. The authors concluded that there was evidence for social determinants of hallway bed use that was likely multifactorial. Even so, results from these academic centers may not be generalizable to community settings.

Solutions

Treating patients in hallways is a natural extension of ED overcrowding [2]. As EDs reach capacity, wait times lengthen and the pressure to add capacity and, by extension, utilize hallway beds, is felt. Many potential solutions to overcrowding and socioeconomic bias in patient care have been put forth. A key example is ACEP’s Emergency Medicine practice committee’s set of recommendations of high impact solutions to ED overcrowding that focus on input, throughput, and output variables as opposed to simply increasing capacity. For example, decreasing input by triaging patients to non-ED settings such as urgent care and increasing output via inpatient hallway boarding can reduce overcrowding and the pressure for hallway bed use. Solutions such as fast track, physicians in triage, and bedside registration are wellknown strategies that have been utilized to increase throughput. Furthermore, protocolization of patient hallway bed assignment can help to reduce bias in placement. This may include an emphasis on obtaining and using objective, clinical characteristics before hallway bed assignment in addition to recording demographic data of patients placed in hallway beds and providing propensity data to triage providers.

A common theme that connects these solutions is the need for transparency, multidisciplinary involvement, and interdepartmental and institutional support. For example, although inpatient hallway boarding has been shown to have tremendous potential in reducing boarding overall, would this solution be acceptable to the inpatient hospital team? Without institutional support and pressure for initiatives that are unsavory to those outside the ED, a solution such as this is unlikely to succeed.

Are systems in place to facilitate transparency in the form of reporting clinical consequences or socioeconomic bias resulting from hallway care? We know that treatment in hallway beds can be harmful for all our patients. Reporting of data on the effects of this practice can therefore be the starting point for interdepartmental and multidisciplinary discussion of possible alternative interventions. Continuing to pivot to these suboptimal spaces for care without further action comes at a cost to those of us working under these conditions and to our patients who are subjected to them. We recommend amplifying potential solutions to this issue like those proposed previously. Overcoming the pressures to continue the use of these spaces is a daunting challenge; however, we owe it to our patients to advocate for alternative solutions and support to provide better care.

ABOUT THE AUTHORS

Dr. Kravitz is chief resident at Beth Israel Deaconess Medical Center Harvard Affiliated Emergency Medicine Residency. He received his dual-degree MD/MBA at Temple University.

Dr. Hunt an assistant professor of emergency medicine at the Wake Forest University School of Medicine and serves as medical director for the adult emergency department at Atrium Health Wake Forest Baptist Medical Center.

Dr. Huang is the PGY-3 chief emergency medicine resident at Ocala Regional Medical Center in Florida.

Dr. Davis is a second-year emergency medicine resident at Emory University. She received her dual-degree MD/MBA at Boston University.

Dr. Rehman is a physician and clinical instructor at CU Anschutz Department of Emergency Medicine. She is a section editor for the ED Administration, Quality and Safety section of the Western Journal of Emergency Medicine.