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Beds in emergency hallways perilous during pandemic, experts say

OSF Heart of Mary as it appears on Google Maps Street View on October 16, 2020.

Carle Foundation Hospital is routinely treating people in beds in the hallways of the emergency room at its Urbana facility on University Avenue, although the practice has come under criticism by health experts.

The experts said the practice raises issues about confidentiality and safety, and could expose those patients and others to other health problems during a pandemic.

An Illinois database on Covid-19 outbreaks show that there have been at least 50 outbreaks in Champaign County, including more than one at Carle facilities and others at long-term health care.

The practice of putting patients in beds in emergency department hallways is generally done because a hospital is at overcapacity and does not have room for patients and is known as “boarding.” Boarding has been criticized because negative effects can include death, preventable disability, prolonged hospital stays and general discomfort. 

A spokesperson for Carle said the practice is required there because of a shortage of hospital rooms for patients, but also to ensure patients with serious issues do not spend hours untreated in a waiting room.

But nursing care can be inconsistent when a patient is boarded, and those who become unstable may not be recognized immediately according to a 2014 article titled “Providing Care in Emergency Department Hallways: Demands, Dangers, and Deaths” in Advances in Emergency Medicine.

John Richards, professor of emergency medicine at University of California, Davis, who co-authored the article, said in a recent interview that there is more fear of spread of the virus when patients are in beds in the hallways. He said when people are suspected of having COVID-19, they should be put into isolation rooms. But, he said, this may not happen with people who are asymptomatic.

“COVID made it an interesting issue because it’s possible that we may be putting not only patients but providers at risk for contracting COVID from hallway care,” Richards said.

Allen Rinehart, the executive director of Carle’s emergency department, intensive-care unit and outpatient services, said the primary reason the hospital uses hallway treatment is because the staff wants to start treating patients as quickly as they can, rather than make them wait for long periods of time in the waiting room.

“Whenever people come to an emergency department, they don’t expect to come to an emergency department and wait six to eight hours to get treatment,” Rinehart said. “Waiting six to eight hours … to see a physician or a medical provider is actually dangerous.”

He added that they do not put anyone with respiratory symptoms in the hallway, and they ask patients to wear a mask.

“The quicker that you can get a patient from the door to see a provider, one, the more satisfied the patient is. Number two, the safer your whole system is because then you have typically a physician laying eyes on the patient, doing an evaluation to determine whether or not this person has some life threatening issues,” Rinehart said.

This month, physicians in Green Bay, Wis. expressed shock and concern over the need to board patients there because they were over capacity during a surge.

“For the first time in the 16 years I have been a medical director, our ED has had to place patients in the hallway,” said Dr. Paul Casey of Green Bay’s Bellin Hospital. “This occurred twice in the last week. If you have not yet accepted the seriousness of this pandemic, now is the time to start. The life of a loved one could be at stake.”

Eric Lofgren, an epidemiologist and associate professor at Washington State University, said hallway care does increase the probability of spread. 

“It’s just not a good setting to be sort of thorough and careful and have a limited group of people who are both exposed to the patient and are exposing patients,” Lofgren said. “If you’re in a hallway, you’re also exposed to everybody in that hallway.” 

However, he said the virus also increases the need for hallway care because more patients are coming in.

OSF Heart of Mary Medical Center, which is nearby to Carle on University Avenue, also treats patients in the hallway on the occasion, but typically for patients that are a threat to themselves, said Staci Sutton, director of nursing operations and practice. If there is not a room available close to the nurses’ station, they will put patients in the hallway near the station so they can be closely watched.

She said their patients are screened for symptoms and that no one goes in the hallway if they are showing symptoms. Patients are also always wearing masks.

Seth Trueger, a Chicago based emergency department physician and a spokesperson for American College of Emergency Physicians, said that when sick, it can be very unpleasant to wait in the hallway.

“You come to the hospital because you’re sick… and now you’re sitting in a hallway, there’s lights on, it’s loud and there’s other people, there are all those unpleasant noises and interactions that you see in emergency departments,” Trueger said. “It’s not a great place to be, especially when you’re sick.”

In addition to the physical issues with the practice, there is a lack of privacy when patients are kept in the hallways, he said. It is easier for people to overhear information about patients’ health when they are not stationed in a room.

Rinehart said that at Carle, many of the hallway stations have curtains to ensure privacy, and he added that physicians try to keep their voices down when talking to a patient.

Richards and his co-authors M. Christian van der Linden and Robert Derlet said in their article that the people usually placed in the hallway are those:

  • Awaiting care but are too unstable to be in the waiting room;
  • Who require active medical or trauma care, but there is not vacant bed available
  • Patients who are waiting to be transferred to an inpatient bed or to another institution;
  • Patients who arrived by the ambulance but do not need immediate care; 
  • Patients who are waiting to be transferred to a psychiatric facility. 

Richards said that there are no set standards or rules on this issue and that it’s dependent on the hospital.

The Centers for Disease Control and Prevention stated in a 2016 report that most American hospitals have boarded patients in the ER for more than two hours. A 2001 study published in the Annals of Emergency Medicine showed that 1 in 5 ER patients are boarded and noted that overcrowding has become a major problem in hospitals.

NPR published an opinion article in 2019 written by two resident physicians in Boston further showing the risks

“Recently, one of us cared for a bedridden patient with chest pain who spent 47 hours in an ER hallway before a spot became available in the cardiac unit,” the article stated.

Prior to the 1990s, boarding was not an issue hospitals always dealt with. Richards said this is caused by emergency departments becoming the source of primary care for many patients.

“We do take care of emergencies, that’s our mandate,” Richards said. “But at the same time, a lot of patients who come, come to get things taken care of that they could technically get cared for through their primary care physician, and many of them don’t even have a primary care physician.”

Trueger said that over-capacity isn’t necessarily about the number of beds a hospital has, but about the flow of the beds. When a patient leaves, that bed has to be cleaned before someone else uses it.

Carle Hospital has a capacity of 70 beds in their emergency department, including hallway beds, Rinehart said. OSF has 20 beds, Sutton said.

There are some short-term solutions to this problem, according to Trueger and Richards. One common one is putting patients upstairs in the in-patient areas where it’s quieter. However, these patients are still in a hallway. 

This is a solution Rinehart said Carle sometimes does.

“Whenever the ED starts getting full and anytime there is space upstairs and we have people that actually need to be admitted, we expedite that transfer from the emergency department to the inpatient areas,” Rinehart said, “so only people that need to be in the ED are in the ED.

Trueger said surgical schedule smoothing — spreading surgeries throughout the week rather than concentrating earlier in the week or day — could also help.

Lofgren said that to avoid hallway treatment, he knows some hospitals are converting areas that aren’t currently being used (like convention halls) into treatment areas. He added that some hospitals are also putting elective surgeries — or surgeries that don’t need to be done right away — on hold in order to keep down capacity.

If a hospital does have to do hallway treatment, Lofgren recommends picking one particular hallway or part of the hospital and putting up temporary barriers.

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