OHSU leaders warn crowded emergency room is hurting finances

The leadership at Oregon Health & Science University in Portland is raising the alarm about financial issues related to a significant decline in hospital admissions for patients seeking specialty care and elective surgeries.

Those patients have been crowded out by people admitted to the emergency department, or who are ready to be discharged from the hospital but can’t get a bed in a rehab or care facility, according to officials.

The number of patients admitted from the emergency department has climbed from 28% of total admissions to 40% in the last five years, according to a presentation to OHSU’s board on Friday.

That’s as the emergency department has become, in effect, an overflow inpatient unit for the hospital, with people needing care stashed in conference rooms, hallway beds and exam rooms.

Related: OHSU, Adventist Health Strike Deal For Overflow Patients

One female elderly patient admitted for a urinary tract infection was relegated to a hallway bed in the emergency department for seven days, according to OHSU Health CEO John Hunter.

She was treated for the infection, but deprived of natural light and surrounded by noise and disturbance. She developed a condition known as hospital delirium “so significant, she needed ICU care,” Hunter said.

At the same time that admissions from the emergency department are on the rise, the percentage of inpatients at OHSU who are there for complex surgeries and cancer, neurologic and cardiovascular care has declined.

Those specialties are key moneymakers for the hospital, as well as part of its unique mission as an academic medical center that performs highly specialized procedures like organ transplants.

The number of transfer patients OHSU has accepted from other hospitals — which include most people seeking that specialty care — has fallen 47 % over five years.

The hospital’s executives say the change in patient mix is a key driver of OHSU’s budget deficits, including a $44 million operating loss over the last nine months.

“It is about patients, but the dollars follow the patients,” said OHSU chief financial officer Lawrence Furnstahl.

OHSU Hospital operates at almost full capacity

The bed shortage is not unique to OHSU. Oregon has fewer hospital beds per capita than most states. In 2022, with 1.66 beds for every 1,000 people, it ranked 49th nationwide.

That’s both a strength and a weakness of Oregon’s health care system. Beds in the state are more likely to be occupied, meaning less waste and expense. But as demands on the health care system are rising, the lean system is contributing to a capacity crisis.

OHSU’s 575 inpatient beds are nearly all full, day and night. The hospital operates at 95% capacity typically.

A new addition, scheduled to open in the next year or two, may relieve some of the pressure. It will add 128 inpatient beds for complex surgery and oncology.

Related: With too many patients and too few colleagues, Oregon nurses say: ‘We’re drowning’

Hunter said the executive team will ask the board at its meeting in June to approve a plan for a “strategic realignment” that would divert patients from the main OHSU emergency department to other places, potentially including OHSU’s partner sites: Portland Adventist Medical Center and Hillsboro Medical Center.

Any effort to divert patients from the emergency department is inherently difficult and legally fraught. A 1986 federal law, the Emergency Medical Treatment and Labor Act, requires emergency departments to assess and stabilize any patient who walks through their doors.

“All of our executive team and front-line leaders are working on this day and night,” Hunter told the board Friday, adding he would not “go into the details” of how reduction of admissions through the emergency department would work.

“It sounds like there are regulatory and other hurdles that we have to overcome,” said board member Chad Paulson, an attorney based in Portland. “We’re going to need to have a comprehensive explanation for how this is going to be executed.”

Plan to cut ER admissions

Other members of the board pointed to the systemic problems filling the emergency department, such as a statewide shortage of beds for patients needing psychiatric care and a lack of social supports for aging baby boomers. Those board members suggested it would take more than just an internal policy shift to address the problems.

“I commend you for your good thinking, and I look forward to hearing how you’ve solved the problem at the next board meeting,” said Sue King, an emergency nurse and board member, to dry laughter from her colleagues.

A letter from Hunter and other hospital leaders to the board, dated April 12, included a few more details on the plan to cut emergency department admissions, including strategies “to move patients from in-person ER visits to virtual visits” and better use of urgent care.

Related: Oregon’s hospitals are struggling, with weeks to go in the respiratory illness season

Chris Kish, a union-represented staff nurse at OHSU, said he appreciated executives paying serious attention to the overcrowding crisis in the emergency department. He said many people showing up in the department could benefit from being connected to urgent care or case management.

At the same time, Kish was concerned that OHSU might try to restrict the number of beds available for patients who arrive in the emergency department.

A policy like that could lead to preferential treatment of more appealing patients, and even longer boarding in the emergency room for patients considered hard to place, Kish said.

“We don’t have a choice about what patients are coming through,” Kish said, “and what admits they may need.”

The surge of people being admitted via the emergency department is, according to Kish, a complex mix. Some are people who deferred medical care during the pandemic are arriving sicker and more likely to require an inpatient bed. Others are complex elderly patients who aren’t getting enough care in assisted living or skilled nursing facilities. Unresponsive patients who have overdosed on fentanyl and need interventions beyond Narcan have become more common as well.

OHSU is, Kish said, the only hospital in the state that is partially state-funded.

“Because of the financial advantages that may bring OHSU, it’s incumbent on them to meet the demand, whoever their patient is” he said.