Bill Dixon, 80, lay on a bed between two white fabric partitions in the hallway of the emergency room at Scripps Memorial Hospital Encinitas on Friday, one of 14 patients waiting for an ER bed to open up.
He had been there for two hours, having arrived from his home in Solana Beach with chest pains and dizziness, pleased with the attention he was getting from medical staff but taken aback by his surroundings.
“This is really unacceptable from a patient’s perspective,” the Solana Beach resident said. “There’s really no privacy.”
On Friday, all 38 of the hospital’s emergency rooms were full, and 20 of them had already been admitted for overnight stays, but no beds were available in the main hospital, forcing them to wait in the ER.
It is a medical malaise the industry calls “boarding”, a phenomenon that local experts say could be exacerbated by a new state law that would expand the circumstances under which residents can be detained by law enforcement and taken to local emergency rooms for evaluation. Because the new law expands the current definition of “gravely disabled” to include those “unable to provide for their own personal safety or necessary medical care,” it is widely expected to most directly affect the unsheltered.
The new law, known as Senate Bill 43, is due to take effect on 1 January and will be the subject of a county hearing on Tuesday where supervisors will discuss delaying its implementation for a year. Some argue that more time would allow for better planning to minimise the impact on already overcrowded emergency rooms, while others, including San Diego’s mayor, argue that such a delay would be cruel to the thousands of people living on city streets who need help now.
Hospitals have been more vocal than usual in the debate, warning that they simply do not have the extra capacity, especially during the busy winter months that typically bring many more respiratory patients into their waiting rooms.
While local data on the overall prevalence of boarding and its impact on emergency department corridors was not immediately available, it is a nationally recognised phenomenon.
The American College of Emergency Physicians recently called boarding in emergency departments a “national public health crisis” and released survey results showing that “nearly half of adults (43 percent) would delay or avoid going to the emergency department if they knew they or a loved one with a serious illness or injury could face extreme delays associated with boarding”.
It is clear that not every hospital in San Diego is experiencing the same level of patient backlog as Scripps Encinitas. Larger Scripps facilities in Hillcrest and La Jolla have fared better over the past week. But at the same time, the problem has been so intense at some sites recently that it has spurred action. UC San Diego Health, for example, recently announced that it had purchased Alvarado Hospital in La Mesa out of concern that its emergency departments were clogged with overflow patients who were being held for far too long in emergency corridors, converted waiting areas and even a repurposed conference room.
Sharp HealthCare, the region’s largest health care provider, said its four hospitals in San Diego, Chula Vista, La Mesa and Coronado had an average of 35 emergency patients a day waiting for admission and had handled nearly 2,500 involuntary holds in the past 12 months. At the same time, these facilities have seen the number of emergency visits they handle in a year increase by 27,000 since 2022.
Across San Diego County, emergency departments regularly hold many patients who should have been transferred to inpatient units. The Hospital Association of San Diego and Imperial Counties said there were 187 boarders reported in emergency departments across the region on Wednesday, 29 November. A total of 127 beds in all local hospitals were awaiting discharge to skilled nursing facilities, and an average of 50 to 70 patients per day were awaiting discharge from behavioural health beds to long-term placement in step-down facilities after completing hospital treatment.
What’s causing this multilevel gridlock?
Dr Scott Eisman, chief operating executive at Scripps Encinitas, said no one has fully explained the phenomenon, although it has worsened since the COVID-19 pandemic.
“What may have happened to some extent is that people with chronic illnesses, older patients, just didn’t get a lot of care in the pandemic, and I think you’re still seeing a lot of that effect, that’s my hypothesis,” Eisman said.
And, he added, A&E departments are just the collection point for a whole system that has been thrown off its rhythm. Many patients, he noted, end up waiting in hallways when they can’t get timely appointments to see their primary care doctors.
That was the case Friday for Aaron DeLaby, 63, a design engineer from Carlsbad, who came in with pneumonia that was not getting better and left him short of breath.
“I had been getting worse for many weeks,” DeLaby said. “The antibiotics weren’t working, they just weren’t doing anything, so I made an appointment with a pulmonologist to find out what the next step was, but they couldn’t get me in until the 28th of December.
“I wasn’t sure if I could wait that long, and they told me to go to the emergency room, so I did.”
His case, Eisman says, is a good example of the breadth of the problem.
“You know, it’s hard to see doctors anywhere right now, not just in hospitals,” he said. “We don’t want to let him go home, we don’t want his illness to get worse, so we just have to do everything we can where we can.”
For DeLaby, that meant hours on a bed in the hallway before a private emergency room opened up. He spent the night in that room and remained there until Friday afternoon.
Doctors and other medical professionals who normally work on inpatient wards came to see him for specialist consultations, blood work, medical imaging and other services.
At the end of the day, he said, he didn’t mind spending his time in the corridor or staying overnight in A&E instead of getting a place in a quieter unit that specialises in looking after longer-term patients. But, he added, many of those on either side of him in the corridor on Thursday had more serious medical problems. Many were elderly and forced to share their medical histories in public.
“I didn’t really care that much about being in the hallway, but I felt like I was kind of intruding on my neighbours,” DeLaby said. “You know, intruding on their stuff.
“You can’t help but hear it, even if you don’t mean to.”