The second in a series of articles examining the reasons for record patient volume and YNHHS’ efforts to overcome capacity challenges.
Full hallway beds are a common sight in all of Yale New Haven Hospital’s Emergency Department locations.
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It's a Wednesday afternoon and there are patients everywhere in the York Street Campus Adult Emergency Department.
The 58 rooms in the A, B and C sides of the ED are full. The 30 “official” hallway beds – those with numbers affixed to the walls or railings beside them – are full. Beds are parked in other hallways normally used only for foot traffic. A section of the ED waiting room is now a rapid-care area for less-seriously ill or injured patients. On the other side of the waiting room, an alcove formerly occupied by a vending machine now houses two patients, as do two bays previously used for registration. This is the scene in early December, before a new COVID-19 surge fueled by the Omicron variant brought even more patients to the ED.
“At this point, we’re using any safe spot that we can find,” said Marissa Ghiroli, RN, an ED nurse for over six years. “I joke that we’re going to need bunk beds.”
A sense of humor is a survival tool in the emergency department, where the unexpected is to be expected. Most staff here thrive on the unpredictability and frenetic pace, but current situations in the EDs at YNHH’s York Street and Saint Raphael campuses and Shoreline Medical Center are testing even the most seasoned staff.
“The ED is almost always busy, and there’s always an element of craziness,” said Tara Donovan, RN, who worked in the York Street Campus ED for 15 years before transferring to the Shoreline Medical Center ED a year and a half ago. “But I’ve never seen it the way it is now.”
Hospital staff nationwide are struggling with the same challenges: physical, mental and emotional exhaustion from the first waves of the COVID-19 pandemic; sicker patients who delayed care during 2020; significant staffing shortages; and the latest COVID-19 surge.
“As soon as information about a new COVID variant comes out, our volume goes up,” said Pegi Vedder, a Shoreline ED technical associate (EDTA) for 17 years, “We’re overwhelmed.”
Emergency Department staff are contending with an additional challenge: a dramatic increase in the number of “boarding” patients like Tom Mordecai. Mordecai came to the York Street Campus ED with abdominal pain, and, after evaluation and testing, was admitted to the hospital. Yet, nearly 24 hours later, he was still in an ED hallway, awaiting a bed on an inpatient unit. Mordecai was taking his hallway stay in stride, especially after calling a relative who works in another hospital emergency department. Thinking he might have a shorter wait for an inpatient bed at the other hospital, Mordecai asked his relative if the emergency department there was less crowded.
“He told me, ‘It’s the same here. Stay where you are,’” Mordecai said.
Some patients who come to the Emergency Department are treated there and, if an ED physician determines they can safely go home, they’re discharged. In other cases, an evaluation performed in the ED indicates that patients need to be admitted to an inpatient unit in the hospital. If there aren’t enough open inpatient beds for these patients, they end up “boarding” temporarily in the ED until an inpatient bed becomes available.
In 2020, the number of emergency department visits at Yale New Haven Hospital and nationwide dropped because many people avoided hospitals during the first waves of COVID-19. Around spring of 2021, when COVID-19 cases dropped and widespread vaccination was under way, people began returning to doctors’ offices and hospitals.
As in the past, chest pain, abdominal pain and alcohol use disorder were the most common conditions that brought people to the ED in 2021. But patients with these conditions were sicker, in part because they put off getting care, said Mark Sevilla, RN, vice president, YNHH Behavioral Health and Emergency Medicine. Sicker patients tend to stay longer in the hospital. Longer stays mean fewer available inpatient beds, which lead to more ED boarding.
The York Street Campus ED has seen a particularly large increase in the number of boarders and length of time they spend in the ED. According to statistics from the Yale New Haven Health and Yale Medicine Joint Data Analytics Team, in 2020, 6.74 percent of patients boarded in the York Street Campus Adult ED for over 24 hours. In 2021, that percentage jumped to 18.91 percent. As of Jan. 13 of this year, 34 percent of patients were boarding over 24 hours.
In the Saint Raphael Campus ED, the percentages of patients boarding over 24 hours increased from 1.32 percent in 2020 to 2.7 percent in 2021. It was 13 percent as of Jan. 13 this year.
Source: YNHHS and Yale Medicine Joint Data Analytics Team
This kind of overcrowding affects all areas of a hospital, but is particularly difficult in an emergency department.“We might be full, but we can’t close our doors,” said Emily DeVaux, RN, Saint Raphael Campus ED charge nurse.
“The patients keep coming,” added Marissa Cimino, RN, assistant patient services manager. “But the place doesn’t get any bigger.”
Finding space for boarding patients is only part of the challenge.
“The boarding crisis in the ED isn’t just about accommodating the number of patients we have; it’s about providing the best care possible to all of our patients,” said Edouard Coupet, MD, an attending physician in the SRC ED.
With more boarding patients staying longer, ED physicians and nurses are doing double duty, providing inpatient care to these patients while also handling emergencies. Most boarding patients have been admitted to medicine units, but some require intensive care while they await inpatient ICU beds.
YNHH’s ED is also seeing more patients with behavioral health conditions such as depression and anxiety, and those abusing substances such as alcohol or drugs, Sevilla said. The York Street and Saint Raphael campuses ED Behavioral Health Units were frequently full before COVID-19; the increase has forced ED leaders to find even more staff and suitable space for these patients. The rise in pandemic-related behavioral health and substance use concerns is occurring nationwide, prompting increased demand for mental health services that were stretched thin even before the pandemic.
“There’s been less access to resources for these patients,” said Dr. Coupet, who is also a Yale Drug Use, Addiction, and HIV Research Scholar. “This compounds problems in an area of health care where resources have historically been scarce.”
On top of caring for sicker patients in overcrowded conditions, ED staff – like employees in other areas of the hospital – are contending with serious staffing shortages. Employees are often asked to work additional hours. Over a recent, three-day period, Bryan Townsend, RN, YSC ED, received 14 texts asking him to come in.
“It’s hard to balance,” said DeVaux. “We need more staff to work, but we don’t want to burn them out.”
“The staffing shortages and volume have been extremely taxing on staff, and challenging in ways I’ve never seen,” said Theresa Aversa, RN, Shoreline Medical Center ED patient services manager.
Employees worry about how the overcrowding and staffing shortages affect the quality of care and patient experience they provide.
“We all want to provide the best care possible to our patients,” Dr. Coupet said. “If we feel we haven’t done that, we feel like we’ve failed.”
This might be the most difficult period many Yale New Haven staff and leaders can remember, but it’s not the first surge. For years, the hospital and health system have been taking steps to manage patient volumes and improve patient flow.
In 2017, Yale New Haven launched the Capacity Coordination Center to help predict and manage surges and other situations that strain resources. One of the staff members in the center is an ED nurse, who helps coordinate the number and types of patients transported to each ED location.
A surge plan YNHH enacted in 2018 includes steps for opening additional adult and pediatric beds to accommodate overflow in areas such as the ED and Behavioral Health. In 2018, the C side section of the YSC Adult ED was converted into a holding unit for admitted patients. YNHH’s Nursing Resource Operations Center staff have been caring for C side patients to ease the burden on the ED.
Over the years, Yale New Haven Health has implemented a number of initiatives to promote on-time inpatient discharges. These include “discharge lounges,” where patients leaving the hospital can wait for transportation. Introduced during the first COVID-19 surge, discharge lounges will soon be reinstated and expanded.
YNHH recently began building a temporary ED annex in the West Pavilion entrance to accommodate 35 patients with less-serious illnesses or injuries and free up beds in the main ED.
ED leaders and staff have come up with their own measures to improve efficiency and patient flow, such as the YSC waiting room rapid-care area and a similar setup in the SRC ED triage area.
ED personnel are part of other efforts throughout Yale New Haven Hospital and Yale New Haven Health System to ease the capacity crunch and mitigate the factors contributing to it.
“Emergency Department physicians and staff are among the most creative, flexible and adaptable professionals in health care,” Sevilla said. “There are very few problems they can’t solve, which is why they are critical to these efforts.”
Along with a sense of humor, ingenuity and flexibility are emergency department survival tools. ED staff also have camaraderie that allows them to work in high-pressure, high-stakes environments day after day.
“It’s tough right now, but we’re doing the best we can,” said Justin Blood, RN, SRC ED. “The team that works here is what makes it doable. These are your friends.”
Ghiroli said she copes with the stress by working out and spending time with her young son.
“Sometimes I just need to go home and cry a little,” she said. “People ask me why I don’t go to a different department. As difficult as the ED is, it’s my home.”
Yale New Haven offers many resources to support employees’ well-being, including free counseling and online programs on stress management and numerous other topics. Visit the Thrive page on the employee intranet to access these resources (network only).
A recent surge in patient volume, combined with numerous boarding patients and staffing shortages, are overwhelming ED staff.
A recent surge in patient volume, combined with numerous boarding patients and staffing shortages, are overwhelming ED staff.
ED staff are adept at maneuvering quickly through hallways crowded with beds, fellow staff and workstations on wheels (WOWs).
In the past few years, the SRC has designated 10 to 15 spaces along the hallway for patients, said Marissa Cimino, RN, assistant patient services manager.
Ernesto Araza Jr., RN, took a new patient’s vitals at the Shoreline Medical Center ED in Guilford. Although there are no inpatient beds at the medical center, the ED has been boarding increasing numbers of patients who are awaiting transport to inpatient units at the hospital’s New Haven campuses (see chart).
No matter how busy the SRC ED gets, Shirley Jackson-Sims, an ED technical associate for 42 years, has never wanted to leave it. “This is home for a lot of us,” she said.
Despite the Shoreline Medical Center ED being “overwhelmed” with patients, Pegi Vedder, EDTA, said she manages to stay calm. “Stress doesn’t make the patients go away.”
Keisha Reid, patient care associate, Nursing Resource Operations Center, took Tom Mordecai’s vitals while he awaited an inpatient bed at the York Street Campus. Mordecai was one of many patients, “boarding” in the ED hallway due to overcrowding.
“We have a lot of camaraderie in the ED,” said Meaghan Goode, physician assistant. “We get through things together.”
Tara Donovan, RN, transferred to the Shoreline Medical Center after 15 years in the YSC ED. The ED is the busiest she’s ever seen it, she said, but “We are very resilient.”
Edouard Coupet, MD, and other ED physicians and staff attribute some of the volume increase to patients whose chronic conditions worsened because they didn’t want to go to the hospital during the first waves of COVID-19.
