On a good day in the emergency room where we work, patients who need to be admitted to the hospital might expect to wait four or five hours, including evaluation and treatment, before they are sent upstairs to a ready bed.

On a bad day, ER patients might wait two or three times as long, and sometimes much longer.

Recently, one of us cared for a bedridden patient with chest pain who spent 47 hours in an ER hallway before a spot became available in the cardiac unit.

Keeping patients in the ER while waiting for an inpatient bed — a practice known as boarding — isn’t unique to the busy teaching hospitals where we work. According to the Centers for Disease Control and Prevention, most American hospitals have boarded patients in the ER for more than two hours while waiting for an inpatient bed.

It’s stubborn problem. A 2001 study suggested that as many as 1 in 5 ER patients is boarded. In 2006 the Institute of Medicine identified boarding as part of a “national crisis” affecting emergency care. In 2016, two-thirds of hospitals reported boarding patients in the ER or an observation unit for more than two hours, compared with 57% in 2009.

Waiting hours for a hospital bed can be maddening for patients and their families. Sometimes literally. Researchers recently found that long waits in ER hallway beds are associated with delirium, a medical condition defined by confusion and disorientation.

But boarding in the ER affects much more than patients’ state of mind. The American College of Emergency Physicians has identified boarding as one of the most important factors in ER overcrowding. And overcrowding, in turn, has been associated with everything from delays in administration of pain medication and antibiotics to longer inpatient stays, greater exposure to medical error, delayed treatment for heart attack and even increased mortality.

To understand why boarding can have so many negative consequences, think of a busy school cafeteria at lunch. No matter how efficient the cafeteria workers are at making and serving the food, processing payment and getting people through the line, no one can sit down to eat if all the tables are occupied with other students.

In our case, the emergency department can be remarkably effective at diagnosis and treatment. But if there’s nowhere for admitted patients to go, the whole operation gets bogged down and everyone’s care suffers.

If boarding is such a problem, why do hospitals allow it to continue?

The answer, as with so many things in our health care system, is complicated. But it has a lot to do with money.

Since 1975 the number of hospitals in America has declined by 30%. That’s more than 1,500 hospitals shuttered, with half a million beds lost.

Market forces have been largely responsible, as technology became more expensive, reimbursement rates were curtailed and hospitals either merged or went bankrupt. Meanwhile, annual ER visits have increased by nearly 50 million since 1995.

It looks like a basic supply and demand problem.

But here’s a curveball: Most hospitals operate, on average, at only about 65% of their total inpatient capacity — and this number has actually dropped since 1975.

How can that be?

Reimbursement is a key part of the puzzle.

Medicare, which provides insurance for about 60 million Americans, sets the bar for how much hospitals are paid, from treating pneumonia to neurosurgery. And those reimbursement rates have strongly favored invasive procedures like surgery, colonoscopy and cardiac catheterization.

Simply managing medical conditions in the hospital is much less lucrative.

Hospitals have a strong financial incentive to prioritize these procedures and to give latitude to the specialists performing them in setting their schedules. As a result, dozens of surgeries might be scheduled for a Monday morning, just a handful the following day and almost none over the weekend.

This approach creates wide variation in the number of postoperative patients needing admission to the hospital on any given day. But one thing’s for sure, a surge in post-op patients needing hospital beds means fewer beds for ER patients, which creates a bottleneck and leads to boarding. The variation in demand causes hospitals to swing between overcrowding and underutilization.

So even though we’re seeing more patients in fewer hospitals, limited capacity may not be the primary issue. It’s that we’re using existing capacity inefficiently.

A 2012 review identified inefficiency rather than insufficient beds as the root cause of boarding. Other sources of inefficiency include restricting certain beds to certain specialties, skeleton staffing during nights and weekends and poor discharge planning.

The silver lining is that efforts to improve efficiency are much less expensive than building a new hospital wing. Smoothing out surgical scheduling, for one, has been shown to yield major improvements. Cincinnati Children’s Hospital increased occupancy to 91% from 76%, made $137 million in extra revenue and avoided a $100 million expansion by rejiggering the surgical schedule and streamlining discharges.

Many hospitals are working on the problem. In the two teaching hospitals where we work in Boston, policies are in place to use observation units, affiliated community hospitals and even “home hospital,” where patients receive care from teams that visit them at home, to spare inpatient beds.

Even so, other hospitals may be falling short. Researchers found in 2012 that a majority of the most crowded hospitals had been slow to adopt the most effective measures to alleviate the bed crunch.

Could legislation be the answer? Perhaps.

In 2005, Britain instituted a maximum length of stay of four hours for all ER patients. It worked — 94% of patients were meeting that goal by 2014, although hospitals there have slipped more recently. Australia, New Zealand and Canada have had similar successes.

A legislative mandate seems far-fetched in the U.S., given the current state of Congress. Medicare has begun offering financial incentives for hospitals to address boarding, and the major accreditation organization for hospitals introduced guidelines on how to improve boarding in 2014. Neither of these measures requires action, though.

Ultimately, we suspect that what is really needed is an overhaul of the current system of financial incentives and reimbursement, coupled with penalties for hospitals that fail to act on the problem.

Until then, we’re sorry if you’re still waiting for that bed.

Clayton Dalton and Daniel Tonellato are resident physicians at Massachusetts General and Brigham & Women’s hospitals, both in Boston.

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Portia Smith’s most vivid memories of her daughter’s first year are of tears. Not the baby’s. Her own.

“I would just hold her and cry all day,” Smith recalls.

At 18, Smith was caring for two children, 4-year-old Kelaiah and newborn Nelly, with little help from her abusive relationship. The circumstances were difficult, but she knew the tears were more than that.

“I really didn’t have a connection for her,” says Smith, now a 36-year-old motivational speaker and mother of three living in Philadelphia. “I didn’t even want to breastfeed because I didn’t want that closeness with her.”

The emotions were overwhelming, but Smith couldn’t bring herself to ask for help.

“You’re afraid to say it because you think the next step is to take your children away from you,” she says. “You’re young and you’re African-American so it’s like [people are thinking] ‘she’s going to be a bad mom.'”

Smith’s concern was echoed by several women of color interviewed for this story. Maternal health experts say women often choose to struggle on their own rather than seek care and risk having their families torn apart by child welfare services.

Nationally, postpartum depression affects one in seven mothers. Medical guidelines recommend counseling for all women experiencing postpartum depression, and many women also find relief by taking general antidepressants such as fluoxetine (Prozac) and sertraline (Zoloft). In March, the Food and Drug Administration approved the first drug specifically for the treatment of postpartum depression.

But those advances help only if women in need are identified in the first place — a particular challenge for women of color and low-income moms, as they are several times more likely to suffer from postpartum mental illness, but less likely to receive treatment.

The consequences of untreated postpartum depression can be serious. A report from nine maternal mortality review committees in the United States found that mental health problems, ranging from depression to substance use or trauma, went unidentified in many cases and were a contributing factor in pregnancy-related deaths. Although rare, deaths of new moms by suicide have also been reported across the country.

Babies can suffer too, struggling to form a secure attachment with their mothers and becoming more likely to develop behavioral issues and have lower cognitive abilities.

‘I was lying to you’

For many women of color, the fear of child welfare services comes from seeing real incidents in their community, says Ayesha Uqdah, a community health worker who conducts home visits for pregnant and postpartum women in Philadelphia through the nonprofit Maternity Care Coalition.

News reports in several states and studies at the national level have found child welfare workers deem black mothers unfit at a higher rate than white mothers, even when controlling for factors like education and poverty.

During home visits, Uqdah asks clients the 10 questions on the Edinburgh Postnatal Depression Scale survey, one of the most commonly used tools to identify women at risk. The survey asks women to rate things like how often they’ve laughed or had trouble sleeping in the past week. The answers are tallied for a score out of 30, and anyone who scores above a 10 is referred for a formal clinical assessment.

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Ayesha Uqdah, a community health worker with Maternity Care Coalition, meets with her client, Chaffon Williams at the Maternity Care Coalition Office in the Mantua neighborhood of Philadelphia on March 13, 2019. Uqdah helps women with high-risk pregnancies in getting the care and education that they need.

Heather Khalifa/Philadelphia Inquirer

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Heather Khalifa/Philadelphia Inquirer

Uqdah remembers conducting the survey with one pregnant client, who scored a 22. The woman decided not to go for the mental-health services Uqdah recommended.

A week after having her baby, the same woman’s answers netted her a score of zero: perfect mental health.

“I knew there was something going on,” Uqdah says. “But our job isn’t to push our clients to do something they’re not comfortable doing.”

About a month later, the woman broke down and told Uqdah, “I was lying to you. I really did need services, but I didn’t want to admit it to you or myself.”

The woman’s first child had been taken into child welfare custody and ended up with her grandfather, Uqdah says. The young mother didn’t want that to happen again.

Screening tools are not one-size-fits-all

Another hurdle for women of color comes from the tools clinicians use to screen for postpartum depression.

The tools were developed based on mostly white research participants, says Alfiee Breland-Noble, an associate professor of psychiatry at Georgetown University Medical Center. Often those screening tools are less relevant for women of color.

Research shows that different cultures talk about mental illness in different ways. African-Americans are less likely to use the term “depression,” but may say they don’t feel like themselves, Breland-Noble says.

It’s also more common for people in minority communities to experience mental illness as physical symptoms. Depression can show up as headaches, for example, or anxiety as gastrointestinal issues.

Studies evaluating screening tools used with low-income, African-American mothers found they don’t catch as many women as they should. Researchers recommend lower cutoff scores for women of color, because women who need help may not be scoring high enough to trigger a follow-up under current guidelines.

Bringing treatment home

It took Portia Smith six months after her daughter Nelly’s birth to work up the courage to see a doctor about her postpartum depression.

Even then, she encountered the typical barriers faced by new moms: Therapy is expensive, wait times are long, and coordinating transportation and child care can be difficult, especially for someone struggling with depression.

But Smith was determined. She visited two different clinics until she found a good fit. After several months of therapy and medication, she began feeling better. Today, Smith and her three daughters go to weekly $5 movies and do their makeup together before each major outing.

But many moms never receive care. A recent study from the Children’s Hospital of Philadelphia found that only one in 10 women who screened positive for postpartum depression at the hospital’s urban medical practice sites sought any kind of treatment in the following six months. A study examining three years’ worth of New Jersey Medicaid claims found white women were nearly twice as likely to receive treatment as women of color.

Noticing that gap, the Maternity Care Coalition in Philadelphia decided to try something new.

In 2018, the nonprofit started a pilot program that pairs mothers with Drexel University graduate students training to be marriage and family counselors. The student counselors visit the women an hour a week and provide free in-home counseling for as many weeks as the women need. Last year the program served 30 clients. This year, the organization plans to expand the program to multiple counties in the region, and hire professional therapists.

It was a gamechanger for Stephanie Lee, a 39-year-old woman who had postpartum depression after the birth of her second child in 2017.

“It was so rough, like I was a mess, I was crying,” Lee says. “I just felt like nobody understood me.”

She felt shame asking for help, and thought it made her look weak. Lee’s mother had already helped her raise her older son when Lee was a teenager, and many members of her family had raised multiple kids close in age.

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Stephanie Lee remembers the period after her son Santeno Adams, 2, was born.

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Kimberly Paynter/WHYY

“The black community don’t know postpartum,” Lee says. “There’s this expectation on us as women of color that we have to be these superhero strong, that we’re not allowed to be vulnerable.”

But with in-home therapy, no one had to know Lee was seeking treatment.

The counselors helped Lee get back to work and learn how to make time for herself — even just a few minutes in the morning to say a prayer or do some positive affirmations.

“If this is the only time I have,” Lee says, “from the time I get the shower, the time to do my hair, quiet time to myself — use it. Just use it.”

This story was reported as a partnership between The Philadelphia Inquirer, for which Aneri Pattani reports, and WHYY. You can read the original version here.

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There’s a new question that anti-hunger advocates want doctors and nurses to ask patients: Do you have enough food?

Public health officials say the answer often is “not really.” So clinics and hospitals have begun stocking their own food pantries in recent years.

One of the latest additions is Connectus Health, a federally funded clinic in Nashville, Tenn. This month, the rear of LaShika Taylor’s office transformed into a community cupboard.

“It’s a lot of nonperishables right now, just because we’re just starting out,” she says, but the clinic is working on refrigeration.

It’s not that patients are starving, Connectus co-director Suzanne Hurley says. It’s that they may have a lot of food one day and none the next. That’s no way to manage a disease like diabetes, she says.

“I can prescribe medications all day, but if they can’t do the other piece — which is a decent diet and just knowing they’re not going to have to miss meals,” she says, “medications have to be managed around all of those things.”

Second Harvest Food Bank of Middle Tennessee, a local food bank, is encouraging more health care providers to consider on-site pantries. The food bank also wants every patient — not just those suspected of being low income — asked about their food situation.

“We’re really pushing for universal screening, so you’re not picking who you’re asking that question to. The doctor already asks you really personal questions, and we don’t think twice about it,” says Caroline Pullen, Second Harvest’s nutrition manager. “I think people have always been scared to ask this question because they didn’t really have the resources of where to send them.”

“Food insecurity,” as it’s known, has become a particular concern among seniors. The anti-hunger group Feeding America found that more than 5 million older Americans don’t have enough food to lead a healthy life — a figure that has doubled in the last two decades.

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Nashville General Hospital’s “food pharmacy” opened in February. Some shelves have high-calorie superfoods for cancer patients. Other foods are low sugar for patients with diabetes or low sodium for those with hypertension. The pantry recently added fresh garlic to help patients trying to lower the salt in their diet but maintain some flavor.

Blake Farmer/Nashville Public Radio

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Blake Farmer/Nashville Public Radio

In response, food banks are increasingly meeting seniors where they get their health care. Hospitals from Utah to Massachusetts are sending patients home with food.

Trudy Hoffman now gets free groceries at her monthly visits to Nashville General Hospital.

“They just asked me, did I want a bag of food to carry home?” she recalls. “And I said, ‘Yeah.’ “

The city-funded hospital started its pantry just for cancer patients in recent years but opened it to all patients this year and received a $100,000 grant in October to fund its expansion.

Organizers call it a “food pharmacy,” following the lead of places like Children’s Hospital of Philadelphia, with patients getting a “prescription” for what to pick up. Some shelves have high-calorie superfoods for cancer patients to keep their weight up. Others have low-sugar staples for people with diabetes or low-sodium items for patients with hypertension.

Vernon Rose, who oversees the Nashville General Hospital Foundation, says no one is surprised to see dozens of patients using the pantry each day.

“Because when you’re in a place like ours, where 40% of the folks can’t even afford their health care, you can imagine the choices they’re making,” she says — such as deciding whether to pay for food or pharmaceuticals.

The pantry operates mostly with grant funding. So Rose says the biggest challenge now is keeping it fully stocked with important but more expensive items like fresh produce and spices, which can be used to help patients keep some flavor while reducing salt in their diet.

This story is part of NPR’s reporting partnership with WPLN and Kaiser Health News.

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