Cate Roser, Contributing Illustrator

Emergency rooms across the nation are severely overcrowded, with potentially catastrophic results for patients and medical professionals alike. 

Two recent Yale co-studies, conducted by Arjun Venkatesh, associate professor and chief of the section of administration in the department of emergency medicine, Alexander Janke, visiting research scientist and Edward Melnick, associate professor of emergency medicine and of biostatistics, identified causes of ER overcrowding and analyzed the effects on patients. 

One study examined the effect of hospital boarding on emergency department overcrowding. The other studied monthly rates of patients who left without receiving care due to this overcrowding. 

“We know [overcrowding] is not just uncomfortable — but also dangerous for patients and staff and results in systematically denying care access to vulnerable populations,” Melnick said. “Many American ERs are functioning in disaster mode on a daily basis … my hope is that the public demands action and accountability such that emergency care is available to them and their loved ones when they need it.”

Emergency medicine became a specialty in the 1960s when the exploding population in the United States needed an increasing amount of unscheduled and emergent care. Today, emergency medicine residency programs accept 2,000 students per year in the United States.

Almost all of these residents work in overcrowded emergency rooms. A study conducted by the Institute of Medicine found that prior to the pandemic, over 90 percent of United States emergency departments reported overcrowding to be a problem, and almost 40 percent reported that overcrowding occurred daily. 

“When it reaches a breaking point, it’s hard to make sure that we give everybody the best possible care,” said Karen Jubanyik, an associate professor of emergency medicine at the Yale School of Medicine. 

Jubanyik broke down the studies. Ultimately, she explained, ER overcrowding boils down to one thing: boarding. Boarding is the process of finding patients a bed, which involves holding patients in the ER prior to transferring them to an inpatient or other observation unit. 

“[Once the] emergency department has decided the patient needs to be admitted, there is no place for them to go in the hospital,” Jubanyik said.

Overwhelmingly, the problem is not so much a lack of beds but of staff. The federal government recommends, on average, a nurse-to-patient ratio of 1-to-5 to maintain proper patient care. Most times, there are empty beds to board the patients in the ER, but there are not enough of the appropriate staff to care for those patients.

When patients cannot be put in a room, they must stay in the emergency room. 

“[It is] impossible to keep up with the amount of people in the ER,” said a Yale student volunteer in Yale New Haven Hospital, who was granted anonymity due to fear of professional retaliation or termination.  

According to Jubanyik, another patient once came in with an infection that required intravenous antibiotics. She was cared for in a hallway for three days and “never even saw the inside of the upstairs of the hospital.” Jubanyik said there were “no showers, not the best nutrition possible, no privacy, lights, noise.” Although she had received the care she needed and was able to leave the hospital, the lack of “good rest, good food” and a calm environment all slowed down her recovery process. 

Patients are often afraid to sit in an emergency room for fear of getting sicker. Jubanyik noted that it seems like “patients and visitors are stacked up on top of each other.” Some days, there was no room to put the incoming patients, and even after being registered, they ended up leaving without being seen, also referred to as LWBS. According to the study on LWBS, researchers found that LWBS rates above even one percent result in patients with real medical emergencies not getting necessary care.

The effect of ER overcrowding on patients is serious, and sometimes even fatal. It also causes serious problems for providers.

“When you feel like you can’t give the best care to your patients, when everyone on the team is overworked and overwhelmed, [there is] moral distress to having more to do than you can possibly do right,” said Jubanyik. “People get burned out. [There is] high turnover. A lot of the nurses have left. When the whole place is new, there’s no one to teach. There were once four people doing a job and now there are two.”

Jubanyik recommended some short-term solutions, but emphasized a need for long-term systemic change. She proposed introducing pipeline programs, which would encourage students as young as junior high to consider healthcare professions. She emphasized that there is a need to get people interested and diversify the medical workforce. According to her, programs like this will require a generation to have an effect, but they are necessary.

“The healthcare system is broken. A lot of people have left. Some hospitals have entirely empty floors. [We need to see] where we can get our workforce.” 

In the short term, Jubanyik said hospitals need to develop spaces where patients can go. There are patients who cannot go home yet but do not need to be in the hospital. Unfortunately, the system right now is not set up to pay for adequate home care for many of these patients.

“The system risks breaking down,” Jubaynik warned. “Bad things could happen.”

The emergency room for Yale New Haven Hospital is located at 20 York St.