Pandemic accelerated existing strains nationwide

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Hospital emergency rooms across the nation are dealing with severe overcrowding. To understand why and what can be done about it, I'm talking with Dr. Bill Paolo. He's the chair of emergency medicine at Upstate.

Welcome back to "The Informed Patient," Dr. Paolo.

Bill Paolo, MD: Thank you for having me.

Host Amber Smith: The Institute of Medicine did a study before the pandemic that showed more than 90% of emergency room directors in the U.S. reported overcrowding to be a problem, and 40% said it was something they dealt with daily.

What has happened over the last three years, during the pandemic?

Bill Paolo, MD: The pandemic dramatically shifted the health care landscape in many different ways. The biggest way by far has been the losing of staff because of the pandemic itself. So we've seen a turnover of around 10% of the health care workforce, and that comprises all of us, doctors, nurses, physician assistants, nurse practitioners, who have left medicine because of the stress of the pandemic, because of the personal health concerns of the pandemic or because of various personal reasons having to do with the pandemic.

So what we're doing, effectively, is going into the other end of the pandemic with a team that is much smaller than the team we had going into the pandemic to care for individuals who need our care.

Host Amber Smith: And it sounds like that's not a quick fix.

Bill Paolo, MD: No, unfortunately. At least as early as 2001, the Institute of Medicine had done a study looking at potential nursing staffing crises, by way of example, and predicted that by 2020 we were going to have a large nursing staff crisis in the country.

And certainly by 2030 was the most dire predictions. And I think what you're seeing is an acceleration of those predictions by almost a decade because of the pressures that the pandemic put upon us. So, the fix is slow, unfortunately, because this is a turnover of skilled individuals coming into the system that we need to recapture.

So we've lost a lot of intellect. We've lost a lot of people who've had a lot of time in the profession to care for individuals.

Host Amber Smith: Is that the only reason for the overcrowding?

Bill Paolo, MD: That's one of the biggest reasons for the overcrowding. But what you have to understand when I talk about that, too, is the emergency department is the end/common pathway of a lot of systems that happen all throughout the health care system.

So, by way of example, if there are less primary care providers for a patient to see, and you can't access primary care providers, you know an emergency department is open 24/7.

On the other end, thinking about it in a different way, if you get admitted to the hospital and, say, you broke your leg and you needed to go to a rehab facility, If there isn't a rehab facility bed to take you, you spend longer times in the hospital, therefore not allowing a patient who is new in the emergency department to move into that bed space.

So all of these create logjams in the system that creates crowding in the emergency department.

Host Amber Smith: Do you know what percent of emergency patients come there without having a primary care provider or without being able to get in to see their primary care provider?

Bill Paolo, MD: There are studies that look at this, and it's variable from geographic region to geographic region. In Central New York, the most recent study said that only around 40% to 50% of primary health care needs are met, and there are some barriers to access to care. When we've studied individuals, we find that there are multiple barriers to access care, even if you've obtained insurance and the ability to get care.

Maybe your doctor isn't open the hours you work, or the doctor's open the hours you work, and so you can't get to your doctor because you need to work. Maybe you have children, and you have to take care of them. Maybe your doctor requires a long bus ride away. So there's multiple access points that make it more difficult.

So when we study it, we find a good number of people are having trouble accessing primary care. And that's probably worsened recently as more people have been driven into the system and more people, in terms of the physician and health care end, have been driven out of the system.

Host Amber Smith: Can you explain what "boarding" is?

Bill Paolo, MD: Sure. So, if you come to an emergency department, and you are sick, and you need to be admitted to the hospital, the next step is to get you a bed within the hospital.

So, say you came into the hospital, and you had chest pain, and we found that we were concerned you were having a mild heart attack that didn't need any acute interventions or surgery, but you did need to be admitted to the hospital to be taken care of by doctors and to be medically optimized and to have rehab, by way of example. What we would then do is move you from the emergency department to an inpatient bed, so, somewhere within the hospital, outside of the emergency department.

What's happening is that the hospitals are so full that there are no available beds for that individual to leave the emergency department to take an inpatient bed.

So a boarder is somebody who needs care rendered by the hospital, but can't leave the emergency department because there isn't a bed for them.

Host Amber Smith: And even if you had more beds, you don't have the staff to take care of people in those beds.

Bill Paolo, MD: Correct. One of the things that's always difficult to explain is that beds aren't just a physical bed.

They are staffed by somebody, because a bed is only an effective hospital bed if there's somebody there, a team, to render you care. So the bed in and of itself is defined as a bed that's available to be taken care of by a team. So it depends on how many nurses, doctors, custodians, food service workers you have in a hospital to make that bed into what a human being needs to render care.

So, effectively, we've had less of those because we've had less staff and that contracts the amount of inpatient space that we would otherwise have.

Host Amber Smith: Well, let me ask you a little bit more about the staffing. In terms of emergency physicians, do you know how many complete residency each year and then will be looking for jobs?

Bill Paolo, MD: Sure. So, the turnover rate for emergency medicine is around 2,700 new physicians are produced every year. Interestingly, in 2020, the American College of Emergency Physicians put out a study that said, given some assumptions about where we were in the teens, we expect to be oversaturated with emergency medicine physicians by 2030.

Now, this was a study that was based upon the presumptions of a certain amount of turnover, a certain amount of medical students that are interested in going into the career, a certain amount of retirements at a basal rate. The problem has been that the past three years have completely blown up those assumptions, and we've lost a lot of physicians, so that data is very unclear what that will look like going forward.

And so what we're seeing now is less medical students, at least this past year, chose to go into emergency medicine than in any previous year. And we don't know whether or not that will be a trend, but it's certainly concerning to say potentially medical students are looking at what the emergency departments have been through in the past three years and saying, "Maybe that's not for me."

And so we don't know what this will look like for the future of the emergency medicine workforce because all of our presumptions are pre-pandemic.

Host Amber Smith: What about nurses? Do they still see the emergency department as an exciting place to work and learn?

Bill Paolo, MD: I think so, but I think the reality of the emergency department has become very difficult recently.

The emergency department generally attracts very altruistic, high-energy individuals who like to be there for people who are having their actual or perceived worst day of their life.

The problem for us recently has been that we do it with teams that are much smaller than we need. So, effectively, the demoralizing part of this is that we are good at our jobs, but we are having trouble doing them because we don't have enough people to do them, so I think that kind of stress also applies to the nursing staff, who have the same sort of predispositions that we all have, which is they want to do the best job they can but frequently feel like the system around them is falling apart so that extra stress gets put on them.

And that what you mentioned earlier, those characteristics, the exciting, interesting place to work and learn, becomes more of a "I'm going to deal with it for a couple of years, so I can go on to a more comfortable place."

And that is a drain of intellect away from a place where we need it, like the emergency department.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with Dr. Bill Paolo. He's the chair of the department of emergency medicine at Upstate, and we're talking about overcrowding in the emergency room.

Now, despite the crowded situation, are people with serious illnesses and injuries still able to receive good medical care in a timely fashion in the emergency department?

Bill Paolo, MD: Yes. I think this is important for everybody to note: The emergency departments are absolutely in crisis, the emergency departments across the country are absolutely busy, busier than they've been, but it's important for everyone to note that we are still the place, the most effective place, the emergency department, to seek acute care for potential or actual life-threatening injuries, medical conditions or what have you.

And we always encourage everyone, if you think you are having one, and you don't know because you're not trained, come to the emergency department, so we can tell you whether or not you're actually having one of these emergencies.

People, if you are considering that this is disconcerting enough to seek care, then come seek care with us.

What we are finding on the flip end, however, to your question, is that when you do come to the emergency department, you are waiting longer than you ever have before. So we are rendering care, and we are getting you back, and our queue is defined by the sickest.

So it doesn't matter when you arrive. It matters what you're arriving with that determines when you get back. So we take care of everyone. It's just that it's taking us longer to take care of people than it had in the past.

Host Amber Smith: Can you give any guidance for a person who's trying to decide between the hospital emergency room versus an urgent care center or something like a specialty orthopedic service?

Bill Paolo, MD: Sure. For urgent care type stuff, I think of this as low-acuity episodic care needs. And what do I mean by that? I mean, it's something that you are otherwise well, but have some sort of condition that is minor to you that needs treatment today. So what would things like that be? If you have a small laceration or a cut, if you have a small infection or a bug bite, if you think you have a cold, or you wanted a COVID test , and you're not very sick.

All of those things are great to go to an urgent care center for. They're good at taking care of these low-acuity episodic needs. What I mean by episodic is it's something that you can't wait for your primary care doctor in a couple weeks. You need it taken care of today. But it's not so bad that you need to go be taken care of at a tertiary-care trauma center (such as Upstate University Hospital), by way of example, so your lacerations, your cuts, your bug bites and what have you.

For things like the orthopedics, like (the) Fly Road (facility), who has a walk-in Ortho Now clinic, things like sprains, strains, I think are, perfect for that. Athletes who are young, who may have potential fractures. Minor trauma goes well there.

Anything that's bigger than that, you fall, you hit your head, you think your arm is broken, your femur (thigh bone), that's the emergency department. That's what we do. That's what we do well. So I think if you know you have a condition that needs care today, but you aren't so sick that you feel that you don't know whether or not you have a life- or limb-threatening condition, you can go to an urgent care.

And the final thing I'll say on that, too, is that urgent cares are generally pretty good at then, if you go there, and they say, "Oh no, this is worse than what we expected," pretty good about sending you to the emergency department once they've identified a condition that may be above and beyond their capabilities.

Host Amber Smith: Well, even though it's crowded and the wait may be a long time at the hospital emergency department, some people can't really avoid coming there. Do you have some tips for making things go a little more smoothly?

Bill Paolo, MD: Sure. It is a busy, crowded place right now. and whatever you can do when you come to our emergency department to kind of get yourself through it, whether you're bringing a book or your iPhone or a charger, anything that will provide you some of your creature comforts that you need to deal with a potential wait. So, whatever it is that you need to deal with that wait I think will help you in the emergency department.

We try to supply food and snacks to patients who can have food and snacks. Not everybody can. If you're coming in with abdominal pain, and we're worried you might have appendicitis and need surgery, we're not going to give you food. But if you're coming in because your elbow hurts, and we don't think you need surgery, we're going to feed you. So anything that gives you comfort while you're waiting.

The other thing I would say is, if you are concerned about your wait, you can always talk to the individuals that are there. We have charge nurses, we have triage nurses, the doctors are there. And we're re=evaluating you in a certain periodicity, usually every one or two hours, to see where you are and looking at our emergency department.

But the anticipation, unfortunately, is that the wait is longer than it ever had been in the past.

Host Amber Smith: So when you come in and you're triaged, you see someone pretty quickly when you come in, then they sort of categorize how urgent you are, right?

Bill Paolo, MD: That's correct. So based upon a number of different items, historical data, what you're complaining of, your vital signs, you get assigned a certain triage level, essentially one through five, with five being the least acute -- you know, I'm here because I need a COVID vaccination, by way of example -- to one being the most acute: I'm here because I'm in full cardiac arrest.

So you get graded with that, and your gradations may change depending upon how conditions change as it goes. But generally, you get into these categories, and we're moving you in and out of the emergency department based upon those categories and where you are and how sick you are in a triage system.

Host Amber Smith: All right, so that's mostly for adults. What is the situation for children who need emergency care?

Bill Paolo, MD: We have a separate pediatric emergency department in the Golisano Children's Hospital. Obviously, the same conditions that we're dealing with in the adult emergency department, we're dealing with the pediatric emergency department.

So, we're still dealing with crowding and staffing issues, but what we try to do is from the age of zero all the way up to 18, take individuals out of the adult emergency department and provide a very separate space, different needs, different type of nursing needs, different sort of support.

We have child life specialists who are there to help individuals and help kids and parents through, potentially, procedures dealing with the emergency department and dealing with the discomfort of needing emergency department care, the scariness of getting an IV, potentially.

So we have specialists that are there to help with all of that. So we very much take kids into a separate emergency department to ensure that they have a much more comfortable place to be seen that is specifically for children.

Host Amber Smith: Thank you for making time for this interview, Dr. Paolo.

Bill Paolo, MD: Thank you. I appreciate your time, and I appreciate the chance to get to talk to the community again.

Host Amber Smith: My guest has been Dr. Bill Paolo, the chair of emergency medicine at Upstate. The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

Find our archive of previous episodes at upstate.edu/informed.

This is your host, Amber Smith, thanking you for listening.