Michigan Medicine confronts national emergency department overcrowding crisis

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When you walk through the doors of Michigan Medicine’s adult emergency department at the University Hospital, you enter a hotspot of healthcare activity. According to Dr. Prashant Mahajan, Michigan Medicine department of emergency medicine chair, the unit contains around 100 beds — not including stretchers overflowing into hallways — and sees an influx of patients that creates a scarcity of both staff and space. Emergency department wait times, patient flow and hospital capacity remain issues at Michigan Medicine, especially as patient volumes continue to increase nationwide.

At Michigan Medicine, ED wait time is defined as the time from patient arrival until they are first seen by a health care provider. In an interview with The Michigan Daily, Mahajan said wait times have increased since the pandemic due to a rise in patient visits, increased complexity and severity of illness and community outpatient resources at risk

“(Wait times) have gone up for multiple reasons,” Mahajan said. “The number of patient visits have gone up. People are living longer and older, so (they) have more chronic problems. Nationally, which is also reflected here, the community resources to where the patients would need to go following either their ER visit or following their inpatient hospitalization, like skilled nursing facilities, all have been impacted because of lack of nursing in the community or lack of mental health resources in the community.”

The Daily requested specific metrics from Michigan Medicine to better understand their capacity, including current and historical emergency department wait times, door-to-balloon time and overall patient volume. In response, Ananya Sen, Michigan Medicine public relations representative, wrote in an email to The Daily that the requested numbers are difficult to quantify in a meaningful way.

“As I understand it, the wait time is highly variable depending on several factors and so having just a numerical average would not capture that nuance,” Sen wrote.

The University Hospital serves as tertiary care, treating complicated and rare illnesses that often require longer hospital stays. Dr. Alexander Janke, clinical assistant professor of emergency medicine, said in an interview with The Daily that when inpatient beds are full, patients wait in the emergency department for a hospital bed, reducing its capacity. 

“When the hospital upstairs is full, patients queue in the ED, ‘boarding’ while they wait for a bed to become available,” Janke said. “At times, EDs dedicate an enormous amount of their space to boarding, thus reducing the functional capacity of the (ED) to take care of new patients coming in the door.”

Wait times are not just the result of an ED bottleneck — in many cases, the problem starts long before a patient shows up at the hospital. Dr. Andrew Ibrahim, associate professor of surgery, studies health care delivery through policy and design. In an interview with The Daily, Ibrahim said patients often turn to the ED when they lack primary care providers and could not identify or manage health issues before they warrant immediate attention. 

“The conditions we studied, like hernias or colon cancer, are ideally identified proactively by a primary care doctor,” Ibrahim said. “When that happens, there is time to plan ahead, refer the patient to a surgeon and do the surgery electively. If there is not a PCP, patients usually do not have that condition identified until it is an emergency, so they come to the ED with symptoms, often pain, and need their surgery right away.”

Mahajan said that because many people face barriers to accessing timely outpatient care, they turn to the ED as their only option even before their health declines.

“Emergency medicine also serves as the safety net for a lot of people,” Mahajan said. “There are a lot of people who cannot access the healthcare system, so even though they may not be very ill in the sense (of) suffering an emergency, they don’t have any place to go.” 

The University Hospital has introduced several measures to address these issues. These include advanced triage providers stationed at the front of the ED, the Hospital Care at Home program for stable patients and coordination with ambulatory specialists to reduce unnecessary visits. The hospital also opened a 26-bed medical short-stay unit in April and is preparing to open the 690,000-square-foot D. Dan and Betty Kahn Health Care Pavilion this fall. 

Michigan Medicine is also exploring data-driven collaboration with other areas of the University, such as the College of Engineering’s Center for Healthcare Engineering & Patient Safety. In an interview with The Daily, Beata Mostafavi, Michigan Medicine public relations manager, said CHEPS’ leadership is focused not only on expanding physical space but also on improving the systems behind emergency care. 

“There is an unwavering focus on ED operations, patient experience and provider wellbeing by the new leadership in the emergency department led by the chair,” Mostafavi said. “We are using innovative approaches such as a joint collaboration with the Center for Healthcare Engineering & Patient Safety to use data-driven approaches to enhance our efficiency without compromising patient safety and use of sophisticated data science tools including artificial intelligence to gain insights into ED operations.”

Behind the beeping cardiac monitors and resident rounds, engineers and consultants track real-time data on the number of patients in the waiting room, those admitted but still in the ED and length of stay. Vincenzo Loffredo, Michigan Medicine business consult intermediate, leads a team that shadows ED providers to identify bottlenecks and test solutions. Loffredo said in an interview with The Daily that one early breakthrough involved stress tests, a diagnostic procedure for patients with chest pain. 

“These are low-risk patients that are occupying a bed and then have to wait overnight which means maybe they have to provide for child care, pet care, having to still sleep in an uncomfortable bed, for something that probably could’ve been turned into an appointment,” Loffredo said. “We found that (free) slots were all located in the morning and the majority of stress test orders came in the afternoon, and therefore those orders would be processed the following morning. So by just changing where those slots were allocated, we were able to reduce the waiting time for these types of patients.”

According to Loffredo, his team is currently investigating two long-standing issues: imaging delays and the unnecessary use of specialty consults. Nursing rising senior Laney Hoving, a system engineering intern at CHEPS who works alongside Loffredo, said in an interview with The Daily that imaging diagnostics are a critical pain point of the team’s investigation.

“Patients often end up waiting hours for these tests and it is typically only after these tests are interpreted that meaningful interventions can be initiated or disposition can be determined,” Hoving said. “As we think about ways to improve these processes, there are two main questions we ask: ‘Is the right patient getting the right test at the right time?’ and ‘Is the process itself streamlined?’ When the answer to either question is ‘no,’ we have our work laid out.”

Hoving said engineers are uniquely positioned to find solutions that clinical teams may not have the time or distance to see from within the dynamic setting of the ED. 

“Everyone is dealing with the next crisis, and there’s not always time to look back at how everything fits together,” Hoving said. “This can lead to cracks in communication and inefficient protocols … In the highly dynamic ED setting, this is a challenge in its own right. This is something that a team of engineers is uniquely positioned to address.”

Mahajan said he hopes any public framing of the issue moves beyond focus on the ED itself.

“The theme is to contextualize ED wait times as a systems issue rather than ED efficiency,” Mahajan said. “This is a national problem.”

Daily News Editor Emma Spring can be reached at sprinemm@umich.edu.

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