The Pitt, a new medical drama drawing viewers into a fictional emergency department (ED), recently premiered on HBO. Touted as one of the most authentic depictions of emergency care in a bustling level 1 trauma center, the show captures a significant problem facing our emergency medical system: ED overcrowding. This is a phenomenon that has gotten worse in recent years for many reasons, particularly due to the practice of hospital boarding.
As you may already know, boarding is the term for when ED staff are expected to find space and provide medical care for patients who have been admitted to other units of the hospital for further specialty care. Say a patient comes to the ED having chest pain. We will diagnose the heart attack and provide life-saving treatment in the ED — such as anti-thrombolytics, heparin, and analgesia — in collaboration with the cardiology team. Then, the cardiology team will bring the patient to the catheterization lab or an inpatient unit for further treatment. But, if cardiology doesn’t have an available bed in their unit, the ED will continue to treat the patient there until a bed opens in cardiology.
Prolonged waiting for an inpatient bed is a daily occurrence that leaves our EDs bursting at the seams — just like in the show. Sometimes, my fellow emergency physicians muse that instead of calling ourselves the Department of Emergency Medicine, we should rebrand as the Department of Hallway Medicine. Hospital “boarders” occupy space and resources that are otherwise needed for ED patients, resulting in an increased risk of medical errors, compromised patient privacy, and increased risk of death or discomfort for all patients in the department, both the ED patients and the boarding ones.
In the second episode of The Pitt, we meet Mr. Milton, who presents to the ED with pain that is eventually attributed to cholelithiasis (gallstones). Although Mr. Milton’s diagnosis seems clear, the charge nurse wisely suggests an electrocardiogram (ECG) to make sure Mr. Milton’s symptoms are not due to any cardiac issues. When a medical student, Dennis Whitaker, checks on him as he is lying in a hallway bed awaiting further treatment, Whitaker discovers that Mr. Milton does not have a pulse. Even as the medical team springs into action, they know the resuscitation will be futile because it is obvious that Mr. Milton has been in cardiac arrest for a prolonged, non-survivable period of time.
As Whitaker continues to beat on Mr. Milton’s chest, refusing to accept what happened, it is clear that he will be leaving his shift with significant moral injury. First and foremost, patients like Mr. Milton deserve better. Furthermore, our trainees and staff deserve better, too.
Mr. Milton’s tragic and possibly intervenable cardiac arrest is a classic example of how ED overcrowding threatens patient safety. The medical team ordered an ECG, yet Mr. Milton died in a hallway bed without telemetry monitoring, an unfortunate victim of the realities of ED overcrowding.
Why was Mr. Milton in a hallway bed and not connected to a monitor? Presumably, the problem is multifactorial — if conditions at the fictional Pitt are like those at many other EDs in the U.S., boarding, unsafe patient-to-staff ratios, and an equipment shortage are all likely contributors. Regrettably, there is also strong data to suggest that Black patients like Mr. Milton are more likely to end up in hallway beds, where they receive worse medical care.
There’s a term for medical errors that occur when we start deviating from the standard of care so frequently that these violations become the new standard: normalization of deviance. “Normalizations” are preventable causes of serious medical errors, and they plague today’s real-life emergency departments as staff work to care for a growing number of patients with woefully inadequate resources.
Under such suboptimal circumstances, clinicians are forced to take on personal, moral, and professional liability for problems generally beyond their control. Patients who are lined up head-to-toe in hallway beds and their families beg and plead with their ED doctors every day to do something about the overcrowded conditions, yet we have few options. As physicians, we are employees. We have much less control over the work environment than patients realize, and we cannot simply shut our doors. I am grateful to The Pitt for underscoring this reality so poignantly.
Fortunately, I work for a hospital system that is exploring innovative solutions to address ED boarding. But boarding is a nationwide problem, requiring broad changes. Possible strategies to alleviate boarding include increasing both ED and inpatient staffing (often, there are open beds in the correct unit that cannot be used due to staffing shortages); establishing protocols to admit patients to the correct service efficiently; building more ED space; expediting labs and imaging; expanding our off-hours capabilities for crucial services like psychiatry evaluations and advanced imaging; and moving admitted patients to the hallway of the correct unit where the appropriate unit’s staff can care for them there rather than in the already overcrowded hallways of the ED.
However, these hospital-specific solutions will not fully resolve ED boarding until more regional and national systemic efforts are in place. For example, inpatient units cannot free up hospital beds for new patients without having appropriate skilled nursing and rehabilitation facilities available. As more of these facilities close, ED boarding continues to worsen. In the meantime, physicians and patients alike should engage hospital administrators and legislators to advocate for solutions to this unacceptable situation.
While Mr. Milton’s likely preventable death in the hallway of the ED made for a tear-jerking episode, real patients’ lives are at stake. Hospitals and health systems have a moral obligation to the patients they serve to implement solutions to remedy overcrowding and boarding.
Mr. Milton deserved better, and so do we.
Alexis Cordone, MD, MPH, MHS-MEd, is a board-certified emergency physician and a Public Voices Fellow of The OpEd Project. These views are the author’s alone and do not necessarily reflect those of any institutions with which she is affiliated.
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