By Carolyn Joy Sachs, MD, MPH 

“It feels different down here,” she said. I had just approached a young woman in our ED waiting room to apologize for the seven-hour wait to be seen. She looked at me with bloodshot, dark brown eyes and continued, “It feels like … the lower decks … Do you know what I mean?” I placed my hand on her shoulder, acknowledging her analogy with a shudder of complete understanding.

She was a few days postpartum with a baby in our neonatal ICU. The labor and delivery nurses had given discharge instructions “if you have any problems, please let us know.” While visiting her baby early that morning, she began bleeding vaginally and went over to labor and delivery to let them know. They responded, “Well, you’re not pregnant now, so we can’t do anything for you,” as they sent her to the ED in a wheelchair to wait seven hours.

At 1 p.m. in our ED, 30 to 40 people were already waiting to be seen, likely spreading COVID to each other, sitting in close proximity in our waiting room with their simple masks. On this day, like many others, several patients enduring the long waiting were yelling disruptively due to pain or emotional distress; one, who had already waited five hours, became increasingly agitated and violent, requiring a physical takedown by security.

To my patient, it felt like she had gone from the upper decks of the nice, clean, under-populated floor of L and D to the lower decks of a ship, a place commonly referred to as “steerage.”

When I went into emergency medicine over 30 years ago, we were proud to work in an environment that could occasionally be chaotic and unpredictable. We choose emergency medicine to serve the disenfranchised and often desperate human beings who need us.

We felt support from the rest of the hospital, and they admitted our patients quickly so we could move on to care for others. If our patients waited for a while in the waiting room, it wasn’t because of anything that the hospital was doing wrong — it was just a busy night. All of that has changed.

The reason that our waiting room is now chaotic and frightening most of the time is not that our patient volume is overwhelming, it is low to average, and we could take care of all these patients quickly if the majority of our ED beds were not continuously occupied with inpatients.

These “boarding” patients have been admitted to the hospital already but remain in the ED for many hours or even days, waiting for the overcrowded hospital space to be vacated for them.

Why would a hospital allow patients and providers to suffer in such an unworkable situation?

A useful analogy to explain this situation can be found by looking at the airline industry and the practice of “bumping” passengers from oversold flights.

As a grade school-aged child, I remember being afraid that our family would get “bumped” on trips to visit my grandparents in Florida, and we would have to spend hours in the airport waiting for the next flight, or worse, stay home in Cleveland for winter break.

This actually did happen once in the 1970s. Like the airlines, hospitals make more money when they “oversell” beds allowing the extra patients to spill over into the ED space that should be used for evaluation and treatment of ED patients.

Patients admitted from the ED also bring in less revenue and are more likely to have public insurance than planned admissions or transfers from other hospitals to the ICU. The bottom line is the reason hospitals continue to board admitted patients in the ED is because they make more money this way.

I’m happy to report that I haven’t been bumped from an airplane flight since the 1970s. The reason I haven’t been bumped is that the federal government (FAA) stepped up to protect passengers and regulated airlines with legislation making this practice less financially attractive. Airlines now ask for volunteers for oversold flights in exchange for money or vouchers.

Suppose no one volunteers and someone is bumped. In that case, airlines must place them on an alternate flight to their destination and pay them handsomely — a minimum of $675 for more than a one-hour delay to destination and $1,350 for two hours with no upper limit on the passenger-negotiated compensation.

Hospitals, on the other hand, have to do nothing for the displaced ED patients in the waiting room who suffer not only long waits but increased morbidity and mortality from the process of hospital boarding.

Though the issues causing boarding are multifactorial, and most administrations address the boarding situation daily, the weakly implemented measures have been largely ineffective. Real solutions require hospitals to share the pain of a dysfunctional system in new ways.

Emergency departments have already endured several decades of the burden, and it is increasingly unsafe and unfair to our patients, patients who are more likely to have already suffered racial health inequities and often have nowhere else to go.

There are many viable options that are barely explored because there are no financial ramifications. It seems to just be easier to turn a blind eye to a patient suffering in the ED, pretend it doesn’t exist, and keep the rest of the hospital neat and orderly at the expense of the emergency department.

In this crisis, we need the federal and state governments to protect our disenfranchised ED patients and financially penalize hospitals proportionately to their inpatient ED boarding hours.

The current situation cannot be allowed to continue unchecked. It is unfair to our patients, unfair to us — and we are together drowning in the lower decks, watching those in the upper decks board the inadequate supply of life rafts without even looking back down at us.