Just How Bad Was Pandemic Strain on Emergency Wait Times? The Numbers Are In

Patients were twice as likely to leave a U.S. hospital emergency department (ED) before seeing a doctor in 2021 compared with 2017 and spent an unsafe number of hours in hospital hallways awaiting a bed, researchers found.

Drawing from numbers collected by voluntary benchmarking from an electronic health record vendor, the median number of patients who left a U.S. hospital without being seen rose to 2.1% (IQR 0.6%-4.6%) in 2021 compared to 1.1% (0.5%-2.5%) in 2017.

In the worst performing hospitals by that measure, the rate was 10% at the end of 2021, up from 4.4% in January 2020 and 4.3% at the beginning of 2017, Alexander T. Janke, MD, of VA Ann Arbor Healthcare System/University of Michigan in Ann Arbor, and colleagues reported in JAMA Network Open.

"Findings from this cross-sectional study demonstrate the failure of the emergency care system to maintain broad access in the context of pandemic demands," the group wrote. Thus, "existing regulatory and financial incentives may be inadequate to meet challenges of future pandemic waves and other disasters."

In a second analysis of the database published by Janke's group in JAMA Network Open, whenever hospital occupancy was beyond 85%, ED boarding typically went longer than the 4-hour duration considered safe by the Joint Commission, which sets standards for hospitals. Moreover, boarding overall increased through 2020 and 2021, even when hospital occupancy did not rise beyond January 2020 levels.

"The harms associated with ED boarding and crowding, long-standing before the pandemic, may have been further entrenched," Janke and colleagues said.

The study used data from electronic health record behemoth Epic's voluntary peer benchmarking service, with the number of participating hospitals rising from 1,289 in January 2020 to 1,769 hospitals by December 2021.

When occupancy exceeded 85%, the ED boarding time was beyond the 4-hour threshold in 88.9% of hospital-months. In those months, the median boarding time was 6.58 hours compared with 2.42 hours in other hospital months (P<0.001).

Median ED boarding time overall was 2.00 hours (5th-95th percentile 0.93-7.88) in January 2020, which decreased to 1.58 hours (5th-95th percentile 0.90-3.51) in April 2020. In December 2021 it went up to 3.42 hours (5th-95th percentile 1.27-9.14).

They reported median hospital occupancy was highest in January 2020, at 69.6%, then dropped to its lowest point in April 2020 (48.7%) before gradually rising to level off at the end of 2021 (65.8%).

Researchers explained that the analysis was limited by an inability to differentiate hospital occupancy on specific services. They noted that the median boarding time was likely underestimated compared to the actual burden as they were limited to specific data fields within the Epic peer benchmarking service.

"We were not able to address hospital characteristics or local COVID-19 infections or address how the mix of participating hospitals changed over time," Janke and researchers said. "Future research should explore more complex measures like staffing variability and local outbreak burden."

Comment