About a week before Thanksgiving, Kelly Jones sat curled up in a ball in the emergency department at Johns Hopkins Bayview Medical Center, crying — and at times fainting — from a severe pain radiating from her hip down to her knee.
Jones, a 34-year-old East Baltimore resident, recently had been diagnosed with degenerative disc disease, a condition that runs in her family. She’d be getting her first epidural to treat the disease in two weeks, but her pain had become unbearable. She needed help now.
She arrived at the Baltimore emergency department with her father around 9 p.m. About six hours later, a nurse took her vitals and offered a heating pad. The next hour, another hospital staff member gave her two extra strength Tylenol.
Even though Jones left before she saw a doctor, she said the hospital charged her about $140 for her wait in the emergency department. Her father drove her home about 5 a.m.
“I have Tylenol at home,” Jones remembered thinking. “At least I could pass out in my bed.”
For seven years straight, Maryland has come out on top in a race no state wants to win. Besides Washington, D.C., and Puerto Rico, there is no other place in the country where people wait longer in an emergency department to be seen.
Last year, Marylanders spent an average of 228 minutes — nearly four hours — in emergency rooms before leaving, according to U.S. Centers for Medicare and Medicaid Services data. That’s roughly half an hour more than residents of Delaware, the second-worst state.
Legislation is slowly moving through the General Assembly that would create a task force to study why Maryland’s average wait time is so long and develop ways to reduce it.
On Wednesday, the House Health and Government Operations Committee unanimously approved a version of the bill. But the scope of the task force and its membership is still being debated among legislators, patient advocates, hospital administrators and doctors.
Some have expressed consternation over launching yet another study on the problem, which, according to Danna Kauffman, a lawyer representing the American College of Emergency Physicians, has been researched at least seven times in the last two decades.
But if there’s one thing that everybody agrees upon, it’s that the crowding of emergency rooms and the resulting long wait times are a public health crisis that hurts everyone it touches — from patients to nurses, doctors and first responders.
Two days after Jones left Bayview’s emergency department, she went to Howard County General Hospital, where the average wait time is 258 minutes, compared with Bayview’s 300, according to the federal data.
Johns Hopkins Medicine said in statement responding to Jones’ experience that addressing long emergency department wait times is a top priority.
“We are working diligently to improve our own internal processes and, while we do not always have an open bed available for our emergency department patients as quickly as we would like, we do have processes in place to ensure that each patient is quickly assessed and continuously reassessed by a health care clinician to address any urgent medical needs,” the statement read.
At the Howard County emergency department, Jones said, a doctor told her she needed to be admitted. Worried about who would take care of her pets, Jones decided not to stay at the Hopkins-affiliated hospital. Still, she said, it was validating to have a doctor recognize she was experiencing an emergency after not receiving timely treatment at Bayview.
“I was in crisis, and that crisis continued, and I had to seek help elsewhere,” Jones said. “That bothers me. It bothers me because there are people that don’t have an option to go elsewhere. It bothers me because we can do better. There are places that do better.”
A national problem
Though emergency department crowding may be especially severe in Maryland, it’s a problem that exists — and is getting worse — nationwide.
In November, the American College of Emergency Physicians and other organizations wrote to President Joe Biden, urging him to work with health care experts to fix the crisis.
The groups wrote that emergency departments are being brought to a “breaking point” by a practice called boarding — where patients admitted to hospitals are held in emergency departments because there is nowhere else for them to go.
Many of the patients are elderly and waiting for space to open up in a nursing home; even more are behavioral health patients waiting for a spot in a psychiatric inpatient or outpatient program. It’s not uncommon for someone to be boarded in an emergency department for weeks.
Between 2012 and 2019, the share of patients boarding eight or more hours rose from 7% to 16%, according to data from the Association of Academic Chairs of Emergency Medicine.
Still, there are states that have populations similar to Maryland’s — and cities that are close to Baltimore’s size — that have shorter emergency department wait times. Take Tennessee, where residents wait 145 minutes on average before receiving care. Or Minnesota, where the average wait time is 129 minutes — nearly 100 minutes shorter than Maryland’s average wait time.
Sen. Karen Lewis Young introduced Senate Bill 387 to create a task force to figure out why Maryland’s wait times are so much longer than those in similar states.
“We’ve heard a lot of theories about why the wait time is so long,” the Frederick County Democrat said during a hearing last month in the Senate Finance Committee. “Certainly, hospitals, health care workers are understaffed. We have an aging population. A lot of patients who are mentally ill are in emergency rooms, and they shouldn’t be — they should be treated elsewhere. ... But these things are common among all of our sister states. So why does Maryland have a longer wait time?”
As it was originally written, the bill — cross-filed with House Bill 274, sponsored by Democratic Del. Harry Bhandari of Baltimore County — charged the task force with comparing emergency department best practices in Maryland with those in states with similar populations and at least one city of about 500,000 residents and which rank in the top half of states in shortest wait times.
The Maryland Hospital Association, an advocacy group that represents the state’s 60 hospitals and health systems, testified in the bill’s favor at the February hearing, but recommended expanding its scope beyond bed availability and staffing and triage practices.
“We support the goals of this bill, but the problems of ED wait times are the symptom, and we need to cure the disease,” said Erin Dorrien, the association’s vice president of policy, at last month’s hearing.
Before voting the bill out of a House subcommittee, lawmakers adopted many of the hospital association’s suggested changes, including expanding the list of topics to be studied by the proposed task force.
Under the latest version, the task force would dissect the root causes of long emergency department wait times by studying the availability of post-hospitalization care options, the capacity of various parts of the health care system, workforce problems, and the state’s unique regulatory and reimbursement policies, among other issues.
The size of the task force also grew, from seven to 21 members. The group would have three hospital representatives — including one from a hospital in a rural setting and one with a pediatric emergency department — emergency department workers, a behavioral health provider, and a nursing home industry representative, among others.
Lewis Young said Monday she was concerned about the changes. She worries that broadening the study’s scope dilutes the mission of better understanding why the state’s ER wait times are so long. And having so many people on the task force could make coming up with policy recommendations like “herding cats.”
Since she doesn’t serve on the Senate Finance Committee, Lewis Young is unsure how much sway she’ll have in revising the Senate version of the bill. But she said she’s submitted an amendment that would require the NAACP and AARP to be represented on the task force.
She said she also may ask lawmakers to order the task force issue two reports: one after six months with specific recommendations for reducing emergency department wait times and a broader report at the conclusion of the study.
Anna Palmisano, director of the advocacy group Marylanders for Patient Rights, waited 10 hours on a gurney in an emergency department hallway in 2015 while experiencing severe side effects from a medication to treat pneumonia.
She described the revised legislation as “massively bloated” and “a laundry list of wishes for the hospital systems.” She’s concerned that with such a big to-do list, it’s unlikely the task force would be able to propose actionable policy recommendations.
She urged lawmakers keep the task force small and its scope narrow.
“I joked to my husband that it’s, ‘Everything, Everywhere All at Once,’” she said of the edited House bill.
A crumbling health system
But emergency medicine doctors in Maryland and beyond agree that crowding and long wait times can’t be solved by only looking at emergency department practices.
In September 2021, a group of eight doctors wrote an op-ed for the New England Journal of Medicine that described emergency department crowding as a “canary in the health care system” that indicates a breakdown in practices and services outside the ER.
The entire health care system is in shambles, said Dr. Jeffrey Sternlicht, chair of emergency medicine at the Greater Baltimore Medical Center in Towson. Since emergency departments are not allowed under federal law to turn away anyone seeking treatment, waiting rooms are where the undersupply of medical resources and treatment options is most visible.
Even though the problem has been well-studied in Maryland, Sternlicht said he’s hopeful another task force could propose helpful policy recommendations — but only if it takes a global look at the health system and doesn’t try to micromanage emergency departments.
“We are just going to waste much, much needed time if everybody just focuses on emergency department operations,” said Sternlicht, who testified in favor of the hospital association’s amendments last month. “Every emergency department in the state of Maryland and throughout the United States has been focusing on intra-departmental efficiencies over the last decade, two decades. So, [the long wait times are] not coming from emergency department efficiencies.”
One big factor contributing to crowding is Maryland’s shortage of behavioral health services, Sternlicht said. Over the last two or three decades, thousands of psychiatric beds have been closed statewide, he said. Meanwhile, community-based or outpatient behavioral health services haven’t increased.
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Since GBMC shares a campus with Sheppard Pratt, Sternlicht said, many of the patients the hospital’s emergency department sees are behavioral health patients. On any given day, up to 75% of the ER’s resources could be devoted to caring for these patients, Sternlicht said.
Within the past week, a 14-year-old behavioral health patient was finally transferred to another facility from the GBMC emergency department after a 79-day stay, said Greg Shaffer, a hospital spokesperson.
Dr. Peter Hill, senior vice president for medical affairs for the Johns Hopkins health system and a practicing emergency physician at Johns Hopkins Hospital, agreed that a more comprehensive look is needed at the health care system.
One of the biggest drivers of long wait times in emergency departments is a lack of capacity to care for sick patients outside of them, Hill said. He cited a 2021 report from the Kaiser Family Foundation that showed Maryland had the third-fewest hospital beds per capita in the nation.
Under the revised House bill, Dr. Ted Delbridge — executive director for the Maryland Institute for Emergency Medical Services Systems — would participate in the task force, or appoint someone to represent him.
It won’t be his first time looking into emergency department crowding. Over the years, he said, the state agency has participated in six studies on that problem and related ones.
“Hopefully, another study will learn from the prior ones in terms of creating recommendations that are actionable and for which there is follow-through,” he said. “Another study just like the last six probably isn’t going to create the solution we need.”