两项研究显示，美国急诊护理面临越来越严重的压力

Two studies show increasing signs of severe strain in U.S. emergency care

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Despite decades of effort to change emergency care at American hospitals and cope with ever-growing numbers of patient visits, the system is showing increasing signs of severe strain, according to two new studies.

The work has implications for health policy, providing data that shows the key role of the availability of staffed hospital beds in the ability of emergency departments to serve patients, whether or not COVID-19 cases are surging.

The studies, based on electronic health record data from across the country, are published in JAMA Network Open by a team from the VA Ann Arbor Healthcare System, the University of Michigan Institute for Healthcare Policy and Innovation, and Yale University.

Alex Janke, M.D., M.H.S., the lead author of both studies, is a National Clinician Scholar at the VAAHS and IHPI who currently provides emergency care at the VAAHS and at Hurley Hospital in Flint, Mich. He notes that the studies are a limited window into an enormous problem, and better data will be essential to guiding government entities, insurers and health systems into sustainable improvements.

"Emergency departments are the levees on acute care demands in the U.S.," says Janke, who trained at Yale before coming to Michigan. "While once there were decompression periods in even the busiest EDs, what we are seeing here, as others are seeing in Canada and the U.K., demonstrates that the levees have broken."

In one study, the researchers examined the percentage of emergency department patients who left without being seen by a physician – likely due to long wait times in crowded conditions.

The median percentage across all hospitals in the study doubled from 2017 to the end of 2021, from just over 1% to just over 2%.

But then the researchers dove deeper into data from the 1,769 hospitals in the study sample at the end of 2021, dividing them up by percentage of patients who left without being seen.

A full 5% of hospitals had more than 10% of the patients who entered their emergency departments leave before they could have a medical evaluation. That's more than double what it was in the same tier of hospitals in 2017 and the early part of 2020.

In the second study, the researchers calculated the number of hours that emergency department patients who required hospitalization had to wait, or "board", in the ED before they actually got a hospital bed.

They looked at how the overall occupancy of each hospital at the time of boarding was associated with how long patients had to wait in the ED for a bed.

The national accrediting body for hospitals recommends that boarding times be kept below four hours, to prevent delays in care and known safety issues.

But the study shows that when hospitals had more than 85% of their staffed beds already occupied by other patients, admitted patients in emergency departments had to wait for their bed more than four hours nearly 90% of the time. In fact, such patients found themselves waiting on average more than 6.5 hours for a bed, compared with 2.4 hours during times when hospitals were less full.

By the end of 2021, the median boarding times nationally were approaching the maximum recommended time, at 3.4 hours. At the 5% of hospitals with the highest occupancy, median boarding times were more than nine hours.

Nationally, the percentage of hospital beds occupied at any given time didn't change much from 2020 to 2021. But the number of emergency visits grew, and boarding times worsened.

The researchers note that their data source doesn't allow them to dive into what factors made hospitals more likely to have high occupancy, long boarding times or high percentages of emergency department patients leaving before they could be seen.

They do note, however, that the strain isn't evenly distributed across hospitals that have emergency departments.

Boarding and overcrowding in EDs have been a growing issue for over 30 years. Incredible work has been done in the emergency medicine community to make our care better, more accurate and nimbler using limited resources. But without more space and staff in the hospital, and downstream in skilled nursing facilities and across community settings, this crisis will continue."

Alex Janke, M.D., M.H.S., Lead Author

In addition to Janke, the study's authors are Yale's Edward R. Melnick, MD, MHS and Arjun K. Venkatesh, MD, MBA, MHS. "This is not an ED management issue," said Venkatesh, an associate professor of emergency medicine at Yale School of Medicine. "These are indicators of overwhelmed resources and symptoms of deeper problems in the health care system."

全文翻译（仅供参考）

两项新的研究显示，尽管美国医院几十年来一直在努力改变急诊护理，应对不断增长的病人就诊量，但该系统正显示出越来越严重的压力迹象。

这项工作对卫生政策有影响，提供的数据显示，无论COVID-19病例是否激增，配备人员的医院床位的可用性对急诊部门为患者服务的能力都起着关键作用。

这些研究基于全国各地的电子健康记录数据，发表在JAMA网络开放 由来自弗吉尼亚州安娜堡医疗保健系统、密歇根大学医疗保健政策与创新研究所和耶鲁大学的一个小组进行。

Alex Janke，M.D.，M.H.S.是这两项研究的主要作者，是VAAHS和IHPI的国家临床学者，目前在VAAHS和密歇根州弗林特市的Hurley医院提供紧急护理。他指出，这些研究是了解一个巨大问题的有限窗口，更好的数据对于指导政府实体、保险公司和医疗系统实现可持续改善至关重要。

“在美国，急诊部门是紧急护理需求的堤坝，”在来密歇根州之前曾在耶鲁大学接受培训的詹克说，“虽然曾经在最繁忙的急诊部门也有减压期，但我们在这里看到的，就像其他人在加拿大和英国看到的一样，表明堤坝已经决堤。”

在一项研究中，研究人员调查了急诊室病人在没有医生的情况下离开的百分比--可能是因为在拥挤的条件下等待时间长。

从2017年到2021年底，该研究中所有医院的中位比例翻了一番，从刚刚超过1%增加到刚刚超过2%。

但随后，研究人员深入研究了2021年底研究样本中1,769家医院的数据，将其除以未被发现的患者百分比。

整整5%的医院急诊科就诊的病人中，有超过10%的人还没来得及做医学鉴定就离开了，这是2017年和2020年初同级别医院的两倍多。

在第二项研究中，研究人员计算了需要住院的急诊科病人在真正得到医院床位之前必须在ED等待或“登船”的小时数。

他们研究了每个医院在入住时的总体入住率与病人在急诊室等待床位的时间之间的关系。

国家医院认证机构建议，登机时间保持在4小时以下，以防止延误护理和已知的安全问题。

但研究显示，当医院85%以上的床位已被其他病人占用时，急诊科收治的病人有近90%的时间不得不等待四个多小时。事实上，这些病人发现自己平均等待一张床位的时间超过6.5小时，而在医院不太满的时候，这一数字为2.4小时。

截至2021年底，全国的平均住院时间已经接近最大建议时间，为3.4小时，在入住率最高的5%医院，平均住院时间超过9小时。

从全国范围来看，2020年到2021年，任何时候医院床位占用率都没有太大变化，但急诊人次却在增加，住院时间也在恶化。

研究人员指出，他们的数据来源不允许他们深入研究是什么因素使医院更有可能有高入住率、长登机时间或急诊室病人在被看到之前离开的比例很高。

然而，他们确实注意到，这种压力在设有急诊科的医院中并不均匀分布。

30多年来，急诊室的寄宿和过度拥挤一直是一个日益严重的问题。急诊医学界做了令人难以置信的工作，利用有限的资源使我们的护理更好、更准确、更灵活。但如果医院没有更多的空间和工作人员，以及下游的专业护理机构和社区环境，这场危机将继续下去。”

Alex Janke，M.D.，M.H.S.，主要作者

除了扬克，这项研究的作者还有耶鲁大学医学博士爱德华·R·梅尔尼克（Edward R. Melnick）和医学博士阿尔琼·K·文卡特什（Arjun K. Venkatesh）。文卡特什是耶鲁大学医学院（Yale School of Medicine）急诊医学副教授，他说：“这不是急诊室管理问题。这些都是资源不堪重负的迹象，也是医疗系统存在更深层次问题的症状。”

Journal references:

Janke, A.T., et al. (2022) Monthly Rates of Patients Who Left Before Accessing Care in US Emergency Departments, 2017-2021. JAMA Network Open. doi.org/10.1001/jamanetworkopen.2022.33708.

Janke, A.T., et al. (2022) Hospital occupancy and emergency department boarding during the COVID-19 pandemic. JAMA Network Open. doi.org/10.1001/jamanetworkopen.2022.33964.

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