Long waits and hallway beds, as crowded ERs struggle to meet patient demand

Born with only half a heart, Marissa Long has spent three decades accessing lifesaving medical care at UCLA Ronald Reagan Medical Center, but her most recent visits to the ER have been nothing short of a nightmare.

During two separate visits in February, Long spent several days living in a hallway as she sought emergency treatment for rejection of her heart transplant.

One night she was placed in a bed next to the ambulance entry doors where paramedics constantly rushed in and she was unable to sleep. She was moved to a hallway lined with hospital beds that nurses had nicknamed “Narnia,” where she overheard other patients’ private medical information and worried about exposure to germs in her immunocompromised state.

“It’s really never been like this, normally we’d get a room pretty quick, like within a few hours,” said Long, who has accessed care at the hospital more than a hundred times.

At the UCLA Ronald Reagan Medical Center, ER hospital beds overflow into several hallway areas and two inpatient beds are crammed into rooms built for one, hospital officials have confirmed. Patients also get treatment in the an elevator lobby, portions of the waiting room and even an outdoor tent.

Many of the expansions into designation ER overflow spaces were pandemic-era emergency measures, but while COVID has subsided these spaces remain in use.

“Like many hospitals across the state and country, Ronald Reagan UCLA Medical Center is experiencing elevated patient volumes often exceeding those at the height of the pandemic in both the emergency department and inpatient units,” said a UCLA Health spokesperson in a written statement. “To limit pressure on the emergency department so that UCLA Health can continue to receive patients in need of lifesaving, emergent care, certain patients are moved to designated overflow areas within the ED (emergency department) and inpatient units.”

“We are grateful for our patients and their understanding, and we appreciate the resilience of nurses and other employees as we manage these challenging circumstances,” the spokesperson added.

Several hospitals in the greater Los Angeles region are grappling with packed emergency rooms due to a perfect storm of post-pandemic conditions. This includes an influx of patients who delayed care during the pandemic, uninsured individuals utilizing the ER to access medical care, nursing shortages and a shortage of beds in outpatient facilities.

“We continue to be pretty overwhelmed day-to-day, post-COVID. The need is high and the available treatment spaces we have are just not adequate,” said Dr. Emily Johnson, an emergency medicine physician at Keck Medicine of USC and associate medical director of the emergency room at Los Angeles General Medical Center (formerly known as LAC + USC).

Overcrowding impacts patient care and creates challenging working conditions for staff, Johnson said.

“It’s really hard to come to work and feel like you spend most of your day apologizing to people,” said Johnson. “It’s heartbreaking to see someone having terrible stomach pain and sitting in a chair and you would love to get them in a bed and feeling better, but you don’t have a place to put them.”

Johnson works at USC Arcadia, Keck Hospital of USC and the Los Angeles General Medical Center in emergency rooms where she said patients can face up to 16-hour waits to be seen by doctors and will sometimes walk out without getting care.

“Around 20% of the patients who leave without being seen, or before their treatment is complete, end up coming back sick enough to be admitted to the hospital on that returning visit,” she said.

This is tough for ER staff to watch Johnson said, adding that many are still experiencing post-pandemic burnout.

“We still have wonderful doctors and wonderful nurses, but it is an extreme challenge to say the least to take care of all these patients,” said Ronald Reagan UCLA Medical Center ER nurse Dianne Sposito, adding that patients can experience long wait times to get their diapers changed, beds cleaned and teeth brushed.

Kathyrn Muellerchen, a nurse in the Ronald Reagan medical-surgical unit, raised concerns about the continued pandemic-era practice of placing two patients in rooms built for one. Such practices were initially allowed under emergency waivers from the California Department of Health Services, and although the state’s COVID-19 Emergency orders have been lifted, UCLA Ronald Reagan has no plans for winding down the practice.

“If patients aren’t mobile they may need a bedside commode to go to the bathroom and they have to do that in front of another patient, so their dignity is gone right there” Muellerchen said. “Or if we have patients in a shared room and the doctor discusses a very serious diagnosis the other patient can’t help but overhear it, so that’s a privacy violation.”

Delayed healthcare during COVID contributes to patient surge

A group of nurses have urged management at Ronald Reagan to create more capacity by delaying elective surgeries. But, management is reluctant to do so given that delayed healthcare during the pandemic contributed to the problems hospitals are currently experiencing.

In March, a small group of unionized nurses who are members of the California Nursing Association staged a protest outside of Ronald Reagan to draw attention to continued issues related to overcrowding, but have had little success in inspiring policy change.

“Further delaying care for non-emergency patients – as some have suggested – risks patients becoming sicker, thereby exacerbating the situation,” said a UCLA spokesperson.

Dr. Johnson, the emergency medicine physician at Keck Medicine of USC and associate medical director of the emergency department at Los Angeles General Medical Center, said she understands both the perspectives of staff and management.

“The last thing we want to do is continue to defer preventive care, colonoscopies, mammograms, the surgeries that people have been waiting on for years at this point,” she said. “But at the same time, something needs to change.”

Part of the surge in ER patients stems from the fact that many people stayed away from medical settings during the pandemic and as a result a lot of routine, elective and preventative health care was put off, said Dr. Ali Jamehdor, medical director of emergency services at Dignity Health St. Mary in Long Beach.

There is also a long backlog of patients seeking specialist medical care and sometimes, if unable to get an appointment for several months, people will try to access medical care through the emergency department, Johnson said.

Shortage of nurses and outpatient beds means backlogs

Another major issue contributing to long ER wait times is the nursing shortage.

“Patients volumes have caught up to what the numbers were pre-pandemic, but the staffing is still trying to catch up,” said Jamehdor.

Many nurses simply quit the profession during the high stress of the pandemic. Other nurses left their hospitals to become travel nurses because the hours are shorter and the pay better, Jamehdor said.

Russell Pollak, an ER technician at Garden Grove Hospital and Medical Center in Orange County, says his emergency room is often full because there are not enough nurses assigned to inpatient units, and as a result, the ER is not allowed to admit patients.

“It causes a ripple effect where patients are stuck in the ER for an endless period of time and patients keep walking through the door as walk-ins,” he said. “Sometimes we have to close down the hospital to ambulance access because we don’t have enough staff or space to deal with ambulance patients.”

When hospitals have adequate nurses, there still may not be space to move ER patients to inpatient care because hospitals are dealing with a shortage of outpatient beds in recuperative care and residential nursing facilities, Johnson and Jamehdor said.

“From my standpoint, and from what I see from Dignity Health’s standpoint, is that we are well-staffed, but it’s a ‘capacity of beds upstairs’ issue,” said Jamehdor, who oversees the Dignity Health emergency room in Long Beach and is familiar with has insight into seven regional Dignity Health ERs.

“We at times do hold patients in the ER just because there is no capacity to bring patients upstairs,” he added.

Jamehdor said that while Dignity Health hospitals are feeling the impacts of nursing shortages and outpatient bed shortages, they don’t deal with the same volume of patients as public hospitals.

“County hospitals do seem to have a higher volume because patients that are uninsured have a higher tendency to go to these hospitals understanding they are … more likely to get better resources once they are discharged,” he said, referring to outpatient care options.

Hospital inefficiencies can contribute to delays

The shortage of recuperative care and skilled nursing home beds is not under the control of hospitals. But one area where management does have control is in addressing hospital inefficiencies, said USC engineering Professor David Belson, who works with many hospitals to improve processes, reduce costs and increase productivity.

“The healthcare system in this country is really not great,” said Belson. “Compared to the 20 most developed countries, the U.S. system is the most expensive and has the worst outcomes.”

Inefficiencies exist in hospital layouts, administration, data tracking, communication between departments, insurance billing and more, Belson said.

A 2019 study published in the Journal of the American Medical Association found that although the US spends 18% of its GDP on healthcare — more than any other country — between 20 and 25% of U.S. healthcare spending is wasteful.

“I could give you hundreds of examples of places that have inefficiencies… I mean, the fact that we’re still using fax machines to exchange records is the perfect example,” said Johnson, emergency medicine physician with Keck Medicine of USC and associate medical director at Los Angeles General Medical Center,.

Johnson said that small inefficiencies in locating supplies or functioning equipment can delay care by significant amounts of time.

“I might spend 15 or 20 minutes of my shift finding a printer that works to print discharge instructions or locating a patient in a restroom and a cup for urine,” she said. “Those little inefficiencies can create bigger problems.”

Sposito, ER nurse at Ronald Reagan UCLA Medical Center, echoed these sentiments, saying she spends considerable amounts of her shift running around the hospital tracking down technology, medication and supplies.

“I have equipment failures constantly … I find that extremely frustrating,” she said, “If there are certain things are missing you have to run all over to get them and for some of the patients you have to go to four different Pyxises (medication dispensing systems) to get their medications. It’s really time consuming and  feels very disorganized.”

Some experts point to the layout of hospitals as a source of inefficiency.

“Today’s hospitals are designed as collections of individual departments, with limited communication and collaboration between medical sub-specialties. Patients are constantly being moved between different places, which is detrimental for patient experience, overall efficiency and capacity,” wrote a team of architects and medical professionals in an article in the International Journal of Computer Assisted Radiology and Surgery.

Carlos Amato, an author of the study and a healthcare architect at Los Angeles-based firm CannonDesign, believes a patient-focused hospital layout — where specialties are not siloed in different buildings, but are brought to a central patient hub — would lead to greater efficiency and improved care.

But he acknowledged that would require a significant overhaul of hospital design and is not a quick fix solution.

“We have an influx of individuals, many of whom have absolutely no access to primary care or any care or insurance, that are all landing in emergency departments. We’ve crossed the line where the layout of the building isn’t going to make the difference in dealing with that volume,” he said.

Belson said there is a growing understanding that hospital infrastructure was not built to handle the needs and volume of 21st century patients and the movement within hospitals to improve efficiency, communication between departments and delivery of care.

“Twenty years ago there wasn’t a whole lot of focus on productivity and improving performance, now there is and almost every hospital has a department of performance improvement,” Belson said.

For example, performance improvement and patient safety plans are available from UCLA Health, Dignity Health St. Mary Medical Center and Los Angeles General Medical Center, while Garden Grove Hospital and Medical Center shares its efforts to improve performance on its Quality Transparency Dashboard.

Strategies to address ER crowding — such as new hospital layouts and data management systems, and more ER nurses — would take time to implement. Time is also needed to work through the patient backlogs created by delayed care during the pandemic. And, addressing the shortage of outpatient beds and the fact that many uninsured people use the ER for non-emergency care, will require action from leaders outside of hospital management.

So, for the time being, it appears that emergency room employees will have to keep hustling under challenging work conditions and patients will continue contending with long-waits and hallway beds.

Source: Orange County Register