Three years ago, emergency departments across Massachusetts were inundated with patients infected with COVID-19. In my 30-plus years of working in emergency medicine, I had never seen anything like it. No one had. We cared for patients in tents outside the emergency department. We set up hospitals in convention centers and we all worked together to care for our communities when they needed us most.
What is hard to fathom is that some of the state’s emergency departments are in worse shape today than at the peak of the March/April 2020 COVID-19 surge, despite low rates of influenza and COVID-19. This is especially true at tertiary referral centers (facilities that provide highly specialized care for the sickest patients — also known as trauma centers) like Massachusetts General Hospital, Baystate Medical Center, and UMass Memorial Medical Center.
In the trauma center I oversee, UMass Memorial Medical Center, it is not uncommon to have 80 patients boarding in the emergency department waiting for an inpatient bed. This limits our ability to see new patients and accept transfers from smaller community hospitals that have fewer capabilities. For patients with time sensitive, life-threatening illnesses, the inability to get to a tertiary referral center can be the difference between life and death.
There is no easy solution to the state’s tertiary emergency department crisis, but we can mitigate its impact by coordinating the use of the state’s post-acute care beds.
The root cause of the problem in emergency departments is not an increase in demand for emergency care. In general, our emergency department visits are at pre-COVID levels. What has changed is our ability to get patients out of hospitals’ inpatient units and into post-acute care beds, which include skilled nursing facilities, rehabilitation centers, and nursing homes. On average, patients are staying an extra day and a half in our trauma center because of workforce shortages in post-acute care settings. When patients can’t be discharged, new admissions back up in emergency departments, creating the crisis we have today.
Unlike the state’s tertiary referral centers that are running at 115 percent to 120 percent capacity, many of the state’s smaller, less comprehensive hospitals have empty beds. The problem is that they get equal access to post-acute care beds, which sets up the horrible situation that we have today, where community hospitals with empty beds desperately trying to transfer critically ill and injured patients to tertiary centers are turned away because the trauma centers are completely full. This wouldn’t happen if we coordinated the use of the state’s post-acute care beds to ensure we always have capacity at regional trauma centers for transfers.
How can we solve this problem now?
What worked in a pre-COVID world does not work in the present day. However, what worked during the first surge of COVID could help. In the early days of the pandemic, the Office of Health and Human Services, in partnership with the Massachusetts Health and Hospital Association, monitored inpatient capacity at every hospital in the state. Because of this data, we knew exactly how many inpatient beds were available and where so that COVID patients could be appropriately cared for in facilities that had capacity.
If we were to deploy a similar model of monitoring for post-acute care availability, OHHS could prioritize discharges from tertiary referral centers that are beyond their capacity to post-acute care facilities that have capacity. Daily monitoring of capacity needs isn’t simple and will take resources at the state level, but it’s imperative to help solve our capacity crisis.
We also need to empower paramedics to care for patients in their homes under the direction of an emergency physician and not transport everyone to the hospital. This would become commonplace if insurance companies were willing to pay emergency medical services the same amount to care for a patient in their home as they do when the patient is transported to the hospital. It would also result in significant cost savings by reducing emergency department visits while taking pressure off already overwhelmed emergency departments across the state.
Now is the time to take action to support our health care system once again — just like we did in the early days of the COVID-19 pandemic. We need to rally one more time and implement a care coordination system that helps create capacity at the state’s tertiary referral centers. The stakes are high; failure to do so will unnecessarily jeopardize patient safety in Massachusetts.
Dr. Eric Dickson is an emergency physician and president and CEO of UMass Memorial Health in Worcester and chair of the board of directors for America’s Essential Hospitals.