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November 10, 2022

Update on the ED Boarding Crisis: ACEP and 34 Other Organizations Send Letter to President Biden Calling for a Summit

A couple weeks ago, I wrote about a recent meeting with the White House in which ACEP President Chris Kang, MD, FACEP, participated that focused on ways to expand access to COVID testing, vaccines, and therapeutics. During that meeting, Dr. Kang raised the critical issue of boarding in the emergency department (ED) and expressed concern that the crisis will worsen with the expected “winter surge” of COVID, flu, and other respiratory illnesses (which in many respects, has already fallen upon us!). Dr. Kang recommended as a first step that the White House host a summit on boarding in the ED that would bring together key stakeholders from the clinician, hospital, nursing home, emergency medical services (EMS), and patient communities to discuss potential solutions. Well, I’m pleased to announce we have an update for you— and to provide the update, I’m deferring to Laura Wooster, MPH, ACEP’s Senior Vice President for Advocacy and Practice Affairs. Laura has been leading ACEP’s recent effort to follow up on the request that Dr. Kang made to the White House to host a summit, and I can think of no one better than to explain ACEP’s continued work on this urgent problem. Laura, please take it away!

Thanks Jeffrey…. glad to be here to share more on this effort.    

While Jeffrey first wrote about boarding and ED crowding in this blog over a year ago, in the past few months, a new sense of urgency has emerged as we’ve heard from our emergency physician members about what you all are seeing on the ground. Something has changed, and it is clear we are rapidly approaching a tipping point; so, we decided to write a public letter to policymakers to truly sound the alarm on what seemed so far to be a largely silent emergency.

I started to go through old materials to see what messaging had been used in the past and was struck that something very close to the letter that I’d originally been envisioning had already been sent by ACEP on multiple occasions going as far back as 2008 (and I’m sure even before that).

While they were good letters that included all the right data and points, they seemed to have fallen on deaf ears. Why would that be? Well, sometimes an issue can be too overwhelming for policymakers to try to address, and boarding certainly fits that bill! Its cause is systemic and multifactorial, so there is no one fix (or even just three) for which to advocate, and the fact that many disparate stakeholders are involved (e.g., patients, payers, providers, nursing homes, EMS, etc.) allows for a kind of diffusion of responsibility.

So, we needed a new approach. While data is often a vital part of any advocacy strategy, sometimes all the data in the world isn’t enough to convey the true realities of an issue. That’s when it can be helpful to pivot to good, old-fashioned storytelling. We put out a call to ACEP members to anonymously submit to us “the most severe or egregious boarding stories you have witnessed” recently.

Over 100 stories poured in, each more alarming and heartbreaking than the next. Common themes emerged across the stories, so we structured our letter into sections for each of them and added the most illustrative stories for each theme. These were:

  • Patients coming to preventable harm as a result of boarding in the ED;
  • A shift to many patients—even ones severe enough to require admission—just being treated in the ED waiting room without ever getting into the ED treatment area;
  • The recent rise of boarding uniquely impacting pediatric ED patients;
  • Disproportionate impacts on patients in the ED with mental health emergencies;
  • Physicians and nurses burning out as each day they are unable to provide the high-quality patient care they trained for;
  • How staffing shortages—especially on the nursing side—have been a big driver of the recent increase in severity of the situation; and
  • How misaligned economic drivers in our health care system can unintentionally incentivize hospitals to prioritize staff and bed space for more lucrative elective surgery patients, rather than other admissions.

Once finalized, we shared the letter with other groups to sign on. Sign-on letters can play an important role in advocacy, because they show that a much larger constituency than just ACEP is alarmed by the recent increase in ED boarding and crowding. We included patient groups in this outreach to further personalize this issue and take it out of just being a faceless “systems” problem—anyone needing emergency care can be impacted. We also reached out to medical specialties, nursing and other health care provider associations, and public health groups. In the end, 34 organizations signed on in addition to ACEP, representing patient and consumer groups, medical societies, nursing and other provider associations, and public health officials. The individual constituents of all these groups combined definitely exceeds ACEP’s 40,000 members!

On Monday morning, we sent the letter to the President, which reinforced Dr. Kang’s initial call for the White House to convene a summit on this issue with all impacted stakeholders so that we could together collaborate on near- and longer-term solutions. We also copied Department of Health & Human Services (HHS) Secretary Xavier Becerra, given the health care focus of this issue, and Department of Homeland Security Secretary Alejandro Mayorkas. This last addition might seem surprising, but it’s clear the current situation poses a significant preparedness risk for our nation—if overwhelmed EDs can’t address the needs of patients on a “normal” day right now despite their almost superhuman efforts, how could they have the capacity to respond effectively to a mass casualty event or natural disaster?

Advocacy and communications go hand-in-hand, so ACEP’s communications team amplified the letter’s impact by sharing on social media, putting out a national press release to highlight the crisis to the media, and creating a powerful digital storybook of the over 100 stories submitted by our members accompanied by visual media. As a result of these combined efforts, the response to the letter has been strong, and it’s clear many members of the public as well as policymakers had no idea the situation was this bad. ACEP even met with HHS this morning, joined by the American Hospital Association and the Association of American Medical Colleges (AAMC), to discuss the issue and possible next steps.

But this all just a first step in our strategy to address the boarding crisis, with much (much!) more to come. In the near term, Dr. Kang is forming a task force on boarding to help develop concrete solutions for us to bring to policymakers. We are also sharing the White House letter with the National Governors Association, as well as working with ACEP chapters to bring it to each governor in the coming days and further raise awareness of this issue. And yesterday’s congressional midterm elections will bring a new group of members of Congress for us to educate on this issue.

To stay up to date on our efforts to address boarding in the weeks ahead and get advocacy materials like taking points, I encourage you to check in on the new resource page that’s been created on ACEP’s website for this issue.

Until next week, this is Laura (and Jeffrey!) saying, enjoy reading regs with your eggs.

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