The ED or the Hallway? I'll Take Option No. 3

The phrase "hallway medicine" doesn't exactly invoke images of a quality care environment. Not to me, at least. Nevertheless, some providers are beginning to view the notion of shifting emergency department patients to inpatient hallways as preferable to the alternative.

A study at Stony Brook (NY) University Medical Center found that no harm was caused by transferring ED patients to upper-floor hallways when they were ready for admission. Presented at a recent American College of Emergency Physicians meeting in Chicago, the study concluded that the strategy is a way to make the entire hospital responsible for emergency patient care and thus relieve overcrowding in the ED.

I confess I have mixed feeling on this one. The Associated Press quoted the study's lead author, Peter Viccellio, MD, as saying the findings mark "yet another battle cry for hospitals to get off their duffs and stop stacking people knee-deep in the emergency department." Well... yes... crowded emergency departments are a significant problem, to say the least. Boarding patients in the ED because there are no inpatient beds to be had is not an acceptable alternative; in fact, a 2007 ACEP survey of emergency physicians found that 13% of them had experienced patients dying because they were boarded in the ED even after they were admitted to the hospital. Viccellio, Stony Brook's ED clinical director, told the AP that on busy days, the ED would "grind to a halt" before his hospital began using hallways. And when it comes to finding solutions, healthcare certainly needs all the innovative thinking it can get.

But sticking patients in hallways as a matter of policy? Plenty of ED caregivers would probably tell me that they safely provide hallway care all the time and that I should get over it. But what about the privacy implications of hallway medicine? Or the safety issues? Or fire codes? Or the basic question of who cares for these patients?

Ultimately, I just have trouble accepting the premise that ED boarding and hallway medicine are the only alternatives. Our HealthLeaders magazine cover story this past January looked at the steps some hospitals are taking to fix the problems in their emergency departments. In Mississippi, for instance, a 580-staffed-bed hospital developed a "rapid-admit" unit to quickly move patients out of the ED for preadmission procedures like IV insertion. Flagging ED tests as high-priority helped ease lab bottlenecks that exacerbated overcrowding. Other organizations addressed their triage processes to increase efficiency and weed out lower-level primary care cases to get people in and out more quickly and free up space. In short, there are hospitals out there that have found solutions that don't involve ED boarding or inpatient hallways.

That said, I realize that plenty of major ED overcrowding issues can't be solved just by tweaking some triage processes. If half of the ED's beds are filled with holds for the ICU or other areas of the hospital, how is that the ED's fault? And if patients are already receiving care in an ED hallway, are they any less safe in a hallway two floors up?

I'd like to hear from you on this—how is your hospital addressing the issue of ED overcrowding? Do you see hallway medicine as a viable alternative? Beyond the choice between boarding in the ED and inpatient hallway care, what is the best third option? Send me an e-mail—I'd love to hear your thoughts.