Imagine this: a young Maryland mother is rushed by EMS to a nearby emergency department after a severe car crash, a store clerk arrives after being struck by a stray bullet on his way to work, and a man suffers a heart attack on a nearby street corner. All three arrive at the hospital within minutes of each other, all needing critical care. The emergency department (ED) has only one available bed.
Jennifer, an ED nurse, and her team are stretched because they know there is also a person with a severe migraine who has been facing intense pain and throwing up for two days and an elderly person who fell. Both have been waiting over two hours for care. Despite these challenges, Nurse Jennifer and the rest of the ED team roll up their sleeves and get to work saving lives and providing comfort.
Hospital teams face tough decisions—not just about who to treat first, but how to manage an overwhelming and unpredictable influx of patients with limited resources.
Throughput is a critical issue across the nation. The complexity of managing patient care and flow while ensuring high-quality care means that hospitals must continuously adapt and innovate. Despite the best efforts of health care professionals, wait times remain a significant challenge in Maryland, exacerbated by factors beyond the control of hospitals, such as a limited number of hospital beds across the state, a lack of behavioral health and primary care, issues with post-acute care referrals, and payer denials.
Maryland hospitals have not stood idle. Through collaborative efforts like the statewide Maryland Hospital Association Hospital Solutions Collaborative, the General Assembly Hospital Throughput Work Group, and the Health Services Cost Review Commission’s (HSCRC) Emergency Department Dramatic Improvement Effort (EDDIE project), significant strides are being made. Several innovative approaches have emerged as best practices—reducing ED congestion while improving wait times and patient experience.
Impactful hospital initiatives include:
- Dedicated Clinical Pathways to identify stroke, Myocardial Infarction (heart attack), behavioral health crisis, and other patients in need of significant, immediate medical intervention. This brings better outcomes for patients while offloading ambulances more quickly and reducing overall ED wait times.
- FlexCare, FastTrack, or FastED tracks patients with less serious care needs to quickly treat them and make space for those with more serious medical emergencies.
- Waiting Room Care in some cases IV fluids, oral rehydration, or the first dose of antibiotic can be administered while a patient waits. This reduces overall throughput times by getting care started more expeditiously.
- Vertical Care where patients with less severe conditions can be assessed and begin treatment in chairs in a private area, rather than waiting for a bed to become available.
- Observation or Clinical Decision Units are in or adjacent to the ED. Patients who require less intensive treatment are placed in these units where they get accelerated care with the aim to discharge them within 24-48 hours.
- Rapid Discharge or Expediting Teams speed up the lab work, images, and other procedures or consults for inpatients. By expediting these processes for current inpatients, the hospital makes room for ED patients with longer-term medical needs to be moved into the opened beds.
- Discharge or Hospitality Lounges provide inpatients who are medically stable and able to go home with a comfortable space to wait for additional support. These discharged patients go to the lounge to get assistance with transportation, medications, or a nutritious meal, opening a hospital bed.
In addition, there are many other emergency department-based programs including
palliative care, patient navigators, social workers, and community health workers to support needs far beyond the patient’s hospital stay. Follow-up appointments are set, and patients and their caregivers are educated so they have the tools to care for themselves at home. While these processes may actually add to the length of time spent caring for a patient, they ensure each person is safe to go home with the hope that they can avoid readmission.
Back to Nurse Jennifer and her team, they quickly work to stabilize the gunshot victim while getting him to an operating room. The heart attack victim is rushed to the cardiac catheterization lab where a dedicated care team begins life-saving treatment. The expediting team quickly evaluates the young mother. They find she is suffering from severe traumatic brain injury, and she’s immediately sent in for surgery. Of all the patients mentioned, only the young person with the migraine can be treated (in vertical care) and discharged. Though critical patients get immediate care from the ED doctors, nurses, and others, there are no hospital beds to move them to when their procedures are complete.
At the same time, the elderly fall patient has a slight pelvis fracture and cannot be released to his home. It is now past 8 p.m., and there is no way to get the patient’s insurance carrier to approve a move to a skilled nursing facility.
While hospitals are hard at work, there are numerous factors outside of their control that must be addressed at the same time. Access to community-based care, including primary care and behavioral health and substance use disorder services, must be expanded to reduce the burden on emergency departments. Additionally, the post-acute care sector faces workforce shortages, making it difficult to discharge patients who need longer-term support in a timely manner. Matters are made worse by the administrative burden and time associated with denials from insurance companies, especially for patients who are cared for in hospital emergency departments on evenings and weekends.
To address these challenges, we need enhanced capacity in post-acute care environments and a streamlined process for denials from payers. Denials and pre-authorizations make it difficult for hospitals to find the necessary aftercare environments for patients who are medically able to leave.
Progress is being made by hospitals around the state, but we know there is still work to be done across the health care continuum to improve throughput challenges that slow and delay ED discharges. By addressing the broader systemic issues, we can ensure that all Marylanders receive timely, high-quality care when they need it most.
The Maryland Hospital Association
The Maryland Hospital Association (MHA) represents more than 60 hospitals across the state. Composed of community, teaching, and specialty hospitals and health systems and aligned with the American Hospital Association, MHA aims to build healthy communities through healthy hospitals.
Editor’s note: House Bill 1143 took effect on July 1, 2024, and established the Maryland Emergency Department Wait Time Reduction Commission. The Commission will develop strategies and initiatives to recommend to State and local agencies, hospitals, and health care providers that address factors throughout the health care system that contribute to increased emergency department wait times. HSCRC staffs the Commission and will report on its activities, findings, and recommendations by November 1, 2025, and November 1, 2026. The bill terminates June 30, 2027.
