Moving Care Forward in the Emergency Department
A clinician’s perspective on setting a new standard for support in the toughest environments
It’s an all-to-familiar scene: an overcrowded Emergency Department. Patients are boarding in the hallway on hospital stretchers. Beds are full and admissions are delayed. Busy caregivers are fatigued and stretched thin as they care for patients in these often-chaotic conditions.
Today’s Emergency Departments (and hospitals as a whole) need support solutions that go beyond standard hospital stretchers, beds and wheelchairs. They need solutions built for the toughest conditions. We recently sat down with Lori Zapfe, RN, ASN, Associate Manager of Medical Affairs, to hear her perspective on these challenges — and get her input on how durable, caregiver-focused solutions can help move care forward in the ED and beyond.
Lori, can you tell us a little bit about your role at Baxter, as well as the healthcare field?
LZ: My name is Lori Zapfe. I am a registered nurse, and I am an associate manager in the Worldwide Medical Division here at Baxter with 30-plus years of healthcare experience.
From your perspective, what’s the biggest shift in patient flow or hospital operations over the past few years, and how might innovation help?
LZ: Over the last few years, we have seen an increase of […] boarding in our ERs. We've also seen throughput throughout the hospital being decreased due to a number of licensed beds not being staffed. I think innovation could definitely help for those boarding patients that are in the ED, but also throughout the hospital in general. Just getting throughput into that hospital setting, making sure when there's input, there's throughput and then output.
ED and hospital overcrowding have been linked to higher mortality, delays in care and higher complication rates.1
When you think about caregiver burden and satisfaction specifically, what role do you think innovation and medical products play?
LZ: Caregiver burden and satisfaction kind of go together in my opinion. If you can give [them] … the latest and greatest technology, then you're going to have caregiver satisfaction — and that helps decrease the burden.
Can you talk to us a little bit about the reality of ED boarding and hallway medicine? What is it exactly?
LZ: We all know that boarding and hallway medicine [have] been around for years in the ED space. What has changed has been [in] the last few years with the boarding crisis. [The] definition of boarding is somebody that has been … given an admission diagnosis to the hospital, but is waiting for that inpatient bed. And usually it's several hours extended in the ED space for that boarder.
Hallway medicine is a little bit different, where we are bringing patients back when the patient rooms are full in the ED, and we have hallway beds (or recliners, as we might call “vertical care”) to accommodate some of those patients that don't need a private room. [They] would get their assessment done in the hallway, get their treatment and then be on their way. That is something we're not proud of. But when we talk about overcrowding and things, that's something that we have to do to keep the flow of the emergency room going.
“The Joint Commission has identified boarding as a patient safety risk that should not exceed four hours.2
Are there any financial and cost impacts of ED overcrowding/boarding?
LZ: Yes. So when we talk about overcrowding and how [boarding relates] to the financial piece, there are some things we have to think about. When you're … boarding patients, [the cost] is almost double … to care for those boarded patients within the ED space.3 So that's an increase in cost possibly to the customer, the patient. And then if you're boarding patients, there's no room for new revenue to come in. You can't be bringing more patients into the hospital if the hospital is at full capacity. So there are some challenges within that hospital system.
“A 2024 study found that boarding patients in the ED nearly doubled the daily cost of care for the hospital.”3
How does prolonged boarding in the ED impact a hospital and patient care? Specifically, are we seeing increased delays, higher complication rate and any patient satisfaction concerns?
LZ: When we talk about boarding patients in the ED for hours, a lot of things come into play. If you have a critical patient that's in the ED, perhaps they're waiting longer for a consultation, [or] for someone to come down and see them. [Those are] some of the delays that can happen. Patients can get worse over time while they're waiting to be put into that inpatient world. The nurses in the ED don't typically continue [their] care in the ED; they get them stabilized and then transfer them. So that's one of the challenges we have today.
How might caring for patients boarded in ED hallways (what we might call a “chaotic corridor”) impact the cognitive load of staff, and how might this lead to communication issues and risk of medical errors?
LZ: If you think about the cognitive load of nurses in the hallway and what happens with patients while they're in the hallway beds, nurses are constantly moving within the ED space — whether they're coming from one hallway to the next [or] to the nurse's station, and you have hallway patients. So as you're going to complete a task — let's say you're going to drop off some blood work for a patient … and then you get stopped by that hallway patient and asked to do something else.
Your brain can only take in so many things, [or tasks], at once. So then you might be headed to drop that blood off and … you've already forgotten, or you've already gotten another task added. And then you've forgotten what your next task was. Or there's somebody that's calling you on the phone. And it can just be a nightmare with all the different tasks coming at you from one point to another, which then can lead to communication errors with your staff that you're not used to talking with. And also just medication errors in general.
Do you find any ongoing strain of overcrowding and boarding contributing to caregiver burnout and staff turnover?
LZ: Absolutely. Some of the things we've seen over the years with the increase in boarding [are] just stressful situations for staff that they're not used to. For instance, having patients that you have to take care of on a daily basis where you're typically treating and then having them discharge. There's [also] some moral issues with clinicians in the ED space: having to give medicine to somebody that doesn't necessarily need it, but because they're being boarded, they're having to give additional medicine. So there are some increased [stresses, and] the moral clinician decisions that have to be made.
And then, of course, the patient satisfaction is just not there when they have to lay on a hospital stretcher for hours waiting for a bed when they don't feel well. They can't go to the bathroom by themselves. They can't do anything without calling for assistance. So it's definitely a challenge today.
Do you find emergency departments vulnerable to violence against caregivers, especially in the context of boarding realities?
LZ: Yes. The violence in the ED is something that's been a very hot topic recently with our boarded patients and just with the ED environment in general. The violence has increased, whether it be verbal or physical … Four out of five physicians have actually witnessed some type of abuse on staff within the ED,4 which really speaks to putting our staff in danger… Boarded patients that are there longer get angry and do things that you wouldn't normally have to combat if they were already admitted on the floor.
Is there revenue upside or cost reduction for hospitals who address these issues effectively?
LZ: Absolutely. Let's think about the revenue upside. If we can combat the boarding crisis within the hospital [and address] the operational flow, you're always going to have new revenue coming in. So, if we can combat this, get patients where they're stable and moved out of the unit or have the potential products to manage them in the unit, I think there is an upside financially for hospitals. [When] you have input, throughput and then output, your financial gains will be there for your hospital.
What is your perspective on modern product and solution design of medical equipment? How important do you think the role of building with caregivers in mind is?
LZ: I can say with some of our modern medical equipment today, it's … just modern. I think we have some room for some advanced technology and some advancement with how things are done in the healthcare setting. Even though there are regulations, really getting out there and talking with the clinical staff that uses the product is what's important. Because engineers may think it's great how they've designed it, but they're not the ones that are using it in practice. So I think really engaging those caregivers that are using that product [is] what's important — because then you're going to have an overall better product, because you've actually engaged those clinicians [that are] using that product.
“Really getting out there and talking with the clinical staff that uses the product is what's important.”
As we conclude for today, I'd like to address one final question: In your opinion, what makes a tool truly exceptional for caregivers?
LZ: I would say, for the emergency room department especially, the tool that I think would be exceptional would be one that would provide support throughout their entire shift and not break down. And it's built for anything — built for the toughest situation that you might be in when it comes to the emergency department.
“The tool that I think would be exceptional would be one that would provide support throughout their entire shift and not break down. And it's built for anything — built for the toughest situation that you might be in when it comes to the emergency department.”
Care moves fast.
So do the people behind it.
That’s why we’re setting a new standard for support — with and for the clinicians who face the toughest challenges every day. Our next breakthrough is designed for the toughest, and built for what’s next.