Thanks for everyone's insightful comments on the article. I appreciate those people who felt strongly enough to write in with their thoughts on ER crowding and the boarding issue.

I was actually quite surprised by the different types of comments on this article.

First was from healthcare providers who were angry at the suggestion that the people who work in ERs (nurses and doctors) consider insurance status or ability to pay in their treatment decisions - this is certainly not the case and the article did not suggest this. As a fellow provider, I know how hard everyone works to provide the best quality care to everyone.

The second was from patients who have experienced ‘the system'. To you, I was delighted to hear about your good experiences and sorry for your bad experiences in the ER. On behalf of ER providers, we work hard to make emergency care is safe and ensure that everyone receives high quality treatment, regardless of insurance or economic status. We often don't have enough resources (manpower and space) to accomplish this. We are sorry that you were seen the hallway or the nurse was too overloaded to tend to your needs. In many ERs, the systems are just not designed to meet everyday demands. Many ERs are working hard to change practices and cultures that perpetuate suboptimal care.

The third was from the many in healthcare leadership positions who wrote into the WSJ blog: <link>

And the many who emailed Zack and me directly to thank us for writing this article and how we , "Hit the nail on the head." Thanks for the kind words. It was good to be supported by those of you who are in the know.

The fourth was from the nurses who commented on the 'bed-hiding' issue. The point was not to say that anyone is lazy -- you are just as overloaded as we are in the ER. I know that you work very hard, but it was to point out that healthcare incentives are misaligned. The way the system is designed promotes ER boarding.

The fifth was from providers who raised a lot of important points about other problems in the healthcare system that contribute to crowding. These important points included 1) poor access to urgent primary care that drives patients both with insurance AND without insurance into ERs when they can't see their doctors, 2) patients who misuse ER services (i.e. frequent fliers), 3) the on-call crisis where it is often difficult to get specialists to come to the ER and see patients who require urgent specialty services, and of course, 4) the bed crunch given the simultaneous increase in ED visits to above 115 million year and shrinkage of hospital bed capacity, and 5) assorted other reasons. These certainly contribute to crowding - but were not the focus of the article.

While I'm glad that you used this forum to discuss these issues because all are important, the article was about the hospital practice of boarding admitted patients in the ER. And how in some communities with high Medicaid and uninsured populations where hospitals are capacity-constrained (where demand for services exceeds supply on both the ER side and inpatient side), boarding is the profit-maximizing strategy. While Zack and I thought we explained it in the article, I am sorry if this was unclear to some.

Boarding comes about when hospitals are in a constrained situation (high demand) and prioritize elective admissions over ER admissions. The first-come-first-serve practice (FCFS), which is the policy in many hospitals, is a historical remnant from the past where hospitals had too much bed capacity and hospitals had beds available when the patient was medically ready. FCFS still occurs today. To ER providers who read this: ask your hospital administrators what the policy is. Don't be shocked if they tell say, "We prioritize bed requests in the order that we receive them." Elective admissions by their nature are the ‘first-comers' because they are usually scheduled in advance (the guy getting an elective heart operation where the surgery was scheduled 2 weeks ago). ER patients arrive consistently throughout the day. Using FCFS, they are necessarily placed at lower priority. This is why boarding occurs when there is more demand for services than supply. There are those of you who said who would reply, ‘not enough beds'. I would reply, yes and no, there are not enough beds in many hospitals because there are too many elective admissions scheduled given the predictable ER demand. Hospitals run at high occupancy because this is the profit-maximizing strategy because it allows hospitals to maximize elective admissions which offer a higher contribution margin than ER patients. If the opposite happened where ER admissions got priority over elective ones, there would be little to no boarding, but there wouldn't be as many elective admissions. Elective admissions would need to be canceled, rescheduled, or not scheduled at all. As a result, maintaining the FCFS policy and operating at high occupancy allows hospitals to maximize profit per bed per day. To those of you who said, "But ER patients make money for the hospital." I would respond with a quote from one of the authors of the IOM report on ER crowding, "Why mine silver when you can mine gold?"

Think to yourself for those of you who work in ERs in high Medicaid/uninsured communities, have you ever seen your hospitals cancel an elective admission, especially an elective surgery when the ER was crowded? If yes, I would be interested to hear about this and it certainly merits writing a ‘case report' which we usually reserve for unusual medical circumstances. In operations terms, the optimal flow occupancy for hospitals is 85%. Above that, flow slows and people wait. As Zack and I referenced in the article: Waiting is dangerous! When hospitals can operate above 85%, which they do if they can...people wait.

I was actually not shocked to read so many comments from healthcare providers who have worked in the system for so many years and suggested that I, "Go back and check my sources."

Zack and I didn't invent this. For hospital operations managers, this is common knowledge - and for those managers who wrote in saying that this was incorrect - you are misleading the public.

Actually the first source suggesting that I know of was from 1989 and was recently emailed to by my friend Dr. Steve Bernstein from Albert Einstein:

"New York ACEP's position is that present health care reimbursement must undergo revolutionary change before the public can be assured hospital care when they need it most. Many studies have shown that the current DRG (Diagnosis Related Group) reimbursement system rewards hospitals if they fill beds with elective admissions, and places them in financial jeopardy when they fill with emergencies. With high hospital occupancy, emergency patients must compete with elective patients for beds. When hospitals are losing money and fear for their future, it is easy to understand how the economics of reimbursement will dictate the actions that place the emergency patient at lower priority for inpatient beds. The emergency patient is more expensive and more likely to be uninsured. Unless these underlying economic realities are acknowledged and addressed, patients in need of emergency hospital care will continue to suffer needlessly." - Testimony by Mark Henry, MD, to NY State Legislature Health Committee (ca. 1989)

I would also point to the 2006 IOM report which provides finer detail for those of you who are interested in learning more about the crowding and boarding crisis:

<link>

Once again, I thank you again for your interest in this important topic that affects all Americans. Because sooner or later, you and your loved ones will all need to go to the ER. This needs to be discussed in public forums by people who understand the issues and can provide suggestions to hospital administrators and policymakers who have the power to eliminate boarding through objective measurement and accountability for this crisis.

Jesse M. Pines, MD

I appreciate very much what you and your colleague accomplished with the original story and the subsequent reactions to it.

While the overall post accurately reflected the extant context and issues surrounding ED patients who board and the overcrowding of emergency departments, you and your colleague alluded to myth when mentioning nursing ratios and factors around the timeliness of physicially transferring patients to assigned inpatient units. I know - I used to direct exactly those operations - patient flow, patient admission assignments, centralized nurse staffing (and their attendant nurse ratios), and I sat on patient safety and quality committees where we addressed systemwide patient flow. I rounded in the EDs (level one trauma center) several times every day (holidays, evenings, nights and days off, too).

I write about professional nursing issues at Home of the Brave and formerly at Universal Health. I responded to the nursing aspects of this post. Discussion is welcome to advance the causes of nurse and patient advocacy and safety.(And should you want to collaborate in future, I'd be delighted to serve as a nursing/admin operational and systems design resource.)

This Explainer post illustrates why it's critical that nurses be included at the health policy table, in corporate healthcare reportage and in all decisions affecting patient safety and advocacy. It's in the public interest to understand what it is nurses are charged by statue and ethics to do, and under what constraints they operate in order to try to do what the social contract demands.

I'm thrilled that your article is getting such widespread attention and discussion. You have moved the policy discussion forward. That's wonderful!

Thank you, thank you so much for posting all of this and really discussing it. I don't have much to add other than my own experiences. My experiences with doctors are negative, and fairly unproductive. More often than not I will not seek their treatment (while I do understand this is crucial to my continued health). I do not appreciate the "holier than thou" attitude they typically take.

The open and frank discussion of the issue is helpful to me - personally. I also understand that these kinds of discussion can spark change where change is necessary and possible. Thank you for being willing to be a mediator in such a touchy subject.