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For emergency departments, incredible crowding can be normal

Patient beds lined a hallway in the emergency department at Brigham and Women’s Hospital.
Patient beds lined a hallway in the emergency department at Brigham and Women’s Hospital.(Globe Photo/File 2017)

The emergency department at Brigham and Women’s Hospital is so congested that doctors treat patients in hallways. Cancer patients wait near mentally ill patients. Delays can last hours. Some frustrated patients simply walk out, and the hospital at times turns away ambulances seeking to bring others.

With a $52 million expansion project that kicks off April 1, the Brigham will become the latest Massachusetts hospital to significantly enlarge and redesign its emergency department amid what leaders describe as unrelenting crowding.

Emergency medicine doctors said they need more space because the patients today require more intensive care, including those with mental illness and drug addiction, or who are suffering the toxic side effects of cancer treatment. These patients need more time, more tests, more attention.

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“All around the country, overcrowding has been a huge thing,’’ said Dr. Michael VanRooyen, chairman of emergency medicine at the Brigham. “It’s pretty demoralizing for patients and staff when we’re seeing people in the hallway.’’

In Massachusetts, multimillion-dollar projects to expand and renovate emergency departments are planned, underway, or were recently completed in nearly every part of the state: Lahey Hospital & Medical Center and North Shore Medical Center north of Boston; Tobey Hospital to the south; Holyoke Medical Center, Baystate Wing Hospital, and UMassMemorial HealthAlliance in Leominster to the west; and Boston Medical Center.

But these expansions also are taking place as business leaders push to control costs by curtailing emergency department visits by people with minor medical problems. Some wonder whether nicer facilities with quicker services would attract more of these patients with sore throats and ankle sprains, which hospitals are increasingly losing to urgent care centers.

But inside emergency departments, doctors say they — and patients — desperately need breathing room. The Brigham project will give them just that: doubling the size of the department, to 51,000 square feet, and adding 30 beds, with separate areas for oncology patients and behavioral health patients so they can be treated by specialized teams in calmer surroundings.

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Cancer patients now make up nearly 20 percent of Brigham emergency visits, in part due to a partnership with nearby Dana-Farber Cancer Institute, which does not have its own emergency department. And since Dana-Farber has expanded further into suburban communities, more fragile oncology patients are now coming to the Brigham.

At the same time, the Brigham’s inpatient units are usually full, creating backups in admitting patients from the emergency department. Overcrowding can lead to delays in pain treatment and lack of privacy for patients, and burnout among staff.

About 17 percent of the hospital’s more than 63,000 emergency patients a year are treated on cots in corridors, according to the Brigham’s application to the state for approval of the project. Staff are deliberately treating more patients in hallways to help reduce the number of patients who give up and leave before receiving care.

It’s also harder for very ill patients to get in. The Brigham turns away about 2,000 patients a year who seek to come by ambulance or from smaller community hospitals.

VanRooyen acknowledged that a larger emergency department could end up just as crowded if patients cannot be admitted to the hospital more quickly.

He envisions the expanded facility as a sort of Grand Central Station, where doctors redirect patients to various sites for admission, including other hospitals in the Partners HealthCare network such as Faulkner Hospital and Newton-Wellesley Hospital. The Brigham also plans to expand its home hospital program, in which doctors and nurses provide inpatient-level care in patients’ homes, he said.

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VanRooyen said he does not expect the improved emergency department to draw many more patients with minor problems, as those types of visits have been declining over the past several years.

But that remains an open question.

In December, a coalition of business groups announced an ambitious effort to reduce avoidable emergency room visits. The Massachusetts Health Policy Commission, a state agency that studies health care costs, estimated that 39 percent, or about 1 million Massachusetts emergency room visits in 2016, could have been avoided because those patients either did not need immediate attention or could have been treated in a lower-cost setting such as an urgent care center.

While the number of overall emergency department visits has been declining in the state, Massachusetts residents still use them at a rate 11 percent higher than the US average.

“We’re trending in the wrong direction if we’re expanding,’’ said Eileen McAnneny, president of the Massachusetts Taxpayers Foundation, which is part of the coalition.

Emergency medicine leaders disagree. They said urgent care centers are now treating many of these minor cases and that trend shows no sign of slowing. And they believe critics overestimate the number of avoidable visits now in emergency departments.

“The purpose [of expanding] isn’t to just to drive more ED visits,’’ said Dr. Gregory Volturo, chairman of emergency medicine at UMassMemorial Health Care, the dominant health care provider in Central Massachusetts. “It’s to take care of the patients we have in front of us and to modernize.’’

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Six months ago, Volturo said, UMassMemorial Medical Center shut down the “fast track’’ service in the emergency department at its Memorial campus because of a lack of customers with simple garden variety medical problems.

The $40 million expansion at UMass’s Leominster hospital is driven by a different phenomenon: an influx of patients with mental illness and drug addiction. The project, expected to be completed next year, will add 13 rooms to the current 24, and create a secure area for behavioral health patients.

In Salem, North Shore Medical Center plans to open a new emergency department in October. It is part of a $207 million construction project that includes nearly doubling the number of inpatient psychiatric beds, which hospital officials expect will help relieve backups in the emergency department. The number of emergency beds will grow to 84 from 72.

Holyoke Medical Center and Lahey in Burlington both opened larger renovated emergency departments within the last two years.

Dr. Ateev Mehrotra, a professor at Harvard Medical School who has studied emergency department use, said it’s unclear whether making emergency services faster and more comfortable will attract more patients — and drive up medical costs.

Some Massachusetts hospitals market their emergency departments by posting wait times on their websites and touting amenities such as single rooms and fast service.

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It might be tempting for financially struggling hospitals to woo patients with minor medical problems. Treating those low-level conditions tends to be profitable, as patients can be taken care of quickly without much testing or complex treatment.

But “from a societal perspective, this is problematic,’’ Mehrotra said. “It encourages patients to come in for convenience. There is a tension out there.’’


Liz Kowalczyk can be reached at kowalczyk@globe.com. Follow her on Twitter @GlobeLizK.