ERs are now swamped with seriously ill patients — but many don't even have COVID
ERs are now swamped with seriously ill patients — but many don't even have COVID
Inside the emergency department at Sparrow Hospital in Lansing, Mich., staff members are struggling to care for patients who are showing up much sicker than they've ever seen.
Tiffani Dusang, the emergency room's nursing director, practically vibrates with pent-up anxiety, looking at all the patients lying on a long line of stretchers pushed up against the beige walls of the hospital's hallways. "It's hard to watch," she says in her warm Texan twang.
But there's nothing she can do. The ER's 72 rooms are already filled.
"I always feel very, very bad when I walk down the hallway and see that people are in pain or needing to sleep or needing quiet. But they have to be in the hallway with, as you can see, 10 or 15 people walking by every minute."
It's a stark contrast to where this emergency department — and thousands others — were at the start of the coronavirus pandemic. Except for initial hot spots like New York City, many ERs across the U.S. were often eerily empty in the spring of 2020. Terrified of contracting COVID-19, people who were sick with other things did their best to stay away from hospitals. Visits to emergency departments dropped to half their normal levels, according to the Epic Health Research Network, and didn't fully rebound until the summer of 2021.
But now, they're too full. Even in parts of the country where COVID-19 isn't overwhelming the health system, patients are showing up to the ER sicker than they were before the pandemic, their diseases more advanced and in need of more complicated care.
Months of treatment delays have exacerbated chronic conditions and worsened symptoms. Doctors and nurses say the severity of illness ranges widely and includes abdominal pain, respiratory problems, blood clots, heart conditions and suicide attempts, among others.
But there's nowhere to put them all. Emergency departments are ideally meant to be brief ports in a storm, with patients staying just long enough to be sent home with instructions to follow up with their primary care physician or being sufficiently stabilized to be transferred "upstairs" to inpatient units or the intensive care unit.
Except now, those long-term care floors are full too, with a mix of COVID-19 and non-COVID-19 patients. That means people coming to the ER are being warehoused for hours, even days, forcing ER staff to perform long-term care roles they weren't trained to do.
At Sparrow, space is a valuable commodity in the ER: A separate section of the hospital was turned into an overflow unit. Stretchers stack up in halls. The hospital has even brought in a row of brown reclining chairs, lined up against a wall, for patients who aren't sick enough for a stretcher but are too sick to stay in the main waiting room. Still, some of the patients in the brown recliners are hooked up to IVs, while others talk quietly with medical specialists who sit across from them holding clipboards, perched on wheeled stools.
There is no privacy, as Alejos Perrientoz just learned. He came to the ER this particular morning because his arm has been tingling and painful for over a week now. He can no longer hold a cup of coffee. A nurse gave him a full physical exam in the brown recliner, which made him self-conscious about having his shirt lifted up in front of strangers. "I felt a little uncomfortable," he whispers. "But I have no choice, you know? I'm in the hallway. There's no rooms."
"We could have done the physical in the parking lot," he adds, managing a laugh.
On the other side of the ER, beyond a warren of identical-looking hallways and heavy double doors that can be opened only with an employee badge, is Sparrow's ambulance bay. Seventy to 100 ambulances pull in each day. "It's a lot," Dusang says, watching emergency medical service teams wheel their patients over to the triage nurse. "It's the highest I've ever seen in my career."
About three times a week, the ER arrives at a point where it just can't take any more patients, she explains. Then it sends out the alert for ambulances to divert patients to other hospitals. But that's a risky move because Sparrow is one of the only hospitals in this part of the state that's equipped to handle severe traumas. Dusang says it feels like "waving the white flag."
"But you have to do it when you feel unsafe," she says, meaning so crowded that the staff can't provide patients with adequate care. "So although it won't [entirely] keep ambulances from coming in, at least it gives them that awareness that, 'Oh, you know, the ED's in trouble.' "
Even patients who arrive by ambulance are not guaranteed a room: One nurse is running triage here, screening for those who absolutely need a bed and those who can be put in the waiting area.
"I hate that we even have to make that determination," Dusang says. Lately they've been pulling out some of the patients who are already in the ER's rooms, when others arrive who are even more critically ill. "No one likes to take someone out of the privacy of their room and say, 'We're going to put you in a hallway because we need to get care to someone else.' "
The number of ER patients is mostly back to normal, but patients are so much sicker
This isn't just happening at Sparrow.
"We are hearing from members in every part of the country," says Dr. Lisa Moreno, president of the American Academy of Emergency Medicine (AAEM). "The Midwest, the South, the Northeast, the West ... they are seeing this exact same phenomenon."
Although the number of ER visits returned to pre-coronavirus levels this past summer, admission rates, from the ER to the hospital's inpatient floors, are still almost 20% higher. That's according to the most recent analysis by the Epic Health Research Network, which pulls data from more than 120 million patients across the country.
"It's an early indicator that what's happening in the ED is that we're seeing more acute cases than we were pre-pandemic," says Caleb Cox, a data scientist at Epic.
Less acute cases, such as people suffering from health issues like rashes or conjunctivitis, still aren't going to the ER as much as they used to. Instead, they may be opting for an urgent care center or their primary care doctor, Cox explains. Meanwhile, there has been an increase in people coming to the ER with more serious conditions, like strokes and heart attacks.
"Even though we're seeing the overall volumes come back to normal over the summer here, we see that the more acute conditions still remain higher than the pre-pandemic normals, while the lower-acuity conditions still remain below pre-pandemic normals," Cox says. So even though the total number of patients coming to ERs is about the same as before the pandemic, "that's absolutely going to feel like [if I'm an ER doctor or nurse] I'm seeing more patients and I'm seeing more acute patients."
How overwhelmed ERs can affect patient care
Moreno, the AAEM's president, works at an emergency department in New Orleans. She says the level of illness, as well as the inability to admit patients quickly and move them to beds upstairs, has created a level of chaos in the ER that she describes as "not even humane."
At the beginning of a recent shift, she heard a patient crying nearby and went to investigate. It was a man with paraplegia who'd recently had surgery for colon cancer. His large post-operative wound was sealed with a device called a wound vac, which pulls fluid from the wound into a drainage tube attached to a portable vacuum pump.
But the wound vac had malfunctioned, and that's why he had come to the ER. But staffers were so busy that by the time Moreno came in, the fluid from his wound was leaking everywhere.
"When I went in, the bed was covered," she recalls. "I mean, he was lying in a puddle of secretions from this wound. And he was crying, because he said to me, 'I'm paralyzed — I can't move to get away from all these secretions, and I know I'm going to end up getting an infection. I know I'm going to end up getting an ulcer. I've been laying in this for like eight or nine hours.' "
The nurse in charge of his care told Moreno she simply hadn't had time to help this patient yet. "She said, 'I've had so many patients to take care of, and so many critical patients. I started a [IV] drip on this person. This person is on a cardiac monitor. I just didn't have time to get in there.' "
"This is not humane care," Moreno says. "This is horrible care."
But it's what can happen when emergency department staffers don't have the resources they need to deal with the onslaught of competing demands.
"All the nurses and doctors had the highest level of intent to do the right thing for the person," Moreno says. "But because of the high acuity of ... a large number of patients, the staffing ratio of nurse to patient, even the staffing ratio of doctor to patient, this guy did not get the care that he deserved to get, just as a human being."
This unintended neglect is extreme and not the experience of the vast majority of patients who arrive at ERs right now. But the problem is not new: Even before the pandemic, ER overcrowding had been a "widespread problem and a source of patient harm ... reflective of not just individual department performance or even individual hospital performance, but of health system dysfunction throughout the United States," according to a recent commentary in NEJM Catalyst Innovations in Care Delivery.
"ED crowding is not an issue of inconvenience," the authors wrote. "There is incontrovertible evidence that ED crowding leads to significant patient harm, including morbidity and mortality related to consequential delays of treatment for both high- and low-acuity patients."
And it's burning out an already overwhelmed staff.
Burnout feeds staffing shortages, and vice versa, in a vicious cycle
Every morning, Dusang wakes up and checks her Sparrow email with one singular hope: that she will not see yet another nurse resignation letter in her inbox.
"I cannot tell you how many of them [the nurses] tell me they went home crying" after their shifts, she says. "And you just hope they show up the next day for more."
But despite Dusang's best efforts to support her staffers, check on them regularly, talk with them about their careers and make them feel seen, heard and appreciated, she cannot stop them from quitting. And they're leaving too fast to replace, either to take higher-paying gigs as travel nurses, to try a less-stressful type of nursing or to simply walk away from the profession entirely.
Midway through the afternoon shift at Sparrow, a nurse breaks down sobbing. A fellow nurse, Amy Harvey, pulls her into a corner and reminds her to take deep breaths.
"Everybody has a breaking point," Harvey says. "It just depends on the day and the situation ... mine could be in three days. Something comes in that just hits home for some reason, and I need a minute to go take a deep breath."
To help fill the staffing gaps, Sparrow's ER has hired about 20 "baby nurses," a term for brand-new nurses. To bring them on board, the hospital waived its previous requirement for working in the ER — at least one year of nursing experience elsewhere — and many of these new nurses are fresh out of nursing school. Right away, they've begun their careers by diving into the deep end, even though they're still training.
"I need some assistance," one of these new nurses whispers to her supervisor, holding up an IV bag. She can't get the top open. "It just pushes in, doesn't it?"
The veteran nurse takes it and shows her: "You gotta twist it so those line up," she says. With a breathy but grateful "Thaaaank youuuu!" the baby nurse turns and peels off toward the patient's room.
Kelly Spitz has been an emergency department nurse at Sparrow for 10 years. But lately, she has also fantasized about leaving. "It has crossed my mind several times," she says, yet she continues to come back. "Because I have a team here. And I love what I do," she says, but then starts to cry. It's not the hard work or even the stress. It's not being able to give her patients the kind of care and attention that she wants to give them and that they need and deserve.
She still thinks a lot about a particular patient who came in a while ago. His test results revealed terminal cancer. Spitz spent all day working the phones, hustling case managers, trying to get hospice care set up in the man's home. He was going to die, and she just didn't want him to have to die here, in the hospital, where only one visitor was even allowed. She wanted to get him home and back with his family.
"I was willing to take him home in my own car, because we were waiting and waiting and waiting for an ambulance, because they're not available," Spitz said. Finally, after many hours, they found an ambulance to take him home.
Three days later, the man's family members called Spitz: He had died, as she expected. But he had died surrounded by family. They were calling to thank her.
"I felt like I did my job there, because I got him home," she says. But that's a rare feeling these days. "I just hope it gets better. I hope it gets better soon."
At 4 p.m., the emergency department is the busiest it has been all day. The patients waiting in the halls seem especially vulnerable, silently witnessing the controlled chaos rushing by them. One woman is sleeping or unconscious on a stretcher, naked from the waist down. Someone has thrown a sheet over her, so she's partially covered, but part of her hips and legs are bare, and open sores are visible on her calves.
As one shift approaches its end, Dusang faces a new crisis: The overnight shift is even more short staffed than usual.
"Can we get two inpatient nurses?" she asks, hoping to borrow two nurses from one of the hospital floors upstairs.
"Already tried," replies nurse Troy Latunski.
Without more staff, it's going to be hard to care for new patients who come in overnight — from car crashes, seizures or other emergencies.
But Latunski has a plan: He'll go home now, snatch a few hours of sleep and return at 11 p.m. to work the overnight shift in the ER's overflow unit. That means he will be largely caring for eight patients alone, on just a few short hours of sleep. But right now, that is their only, and best, option.
Dusang considers for a moment, takes a deep breath and nods. "OK," she says.
"Go home. Get some sleep. Thank you," she adds, shooting Latunski a grateful smile. And then she pivots, because another nurse is already approaching her with an urgent question. It's on to the next crisis.
Corrections Nov. 2, 2021
A previous version of this story incorrectly identified the source of quoted commentary about ER overcrowding. The commentary was published in NEJM Catalyst Innovations in Care Delivery, not The New England Journal of Medicine.
Previously posted Oct. 27, 2021: An earlier version of this story misspelled Alejos Perrientoz's first name as Alejoz.