ED Boarding - what it does to patients and how to fix it

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Boarding is a prevalent issue in many Emergency Departments (EDs) across the country and throughout the world. It’s an issue that crowds the ED and waiting room and frustrates providers. The Institute of Medicine has called boarding the leading safety concern for First World EDs. Boarding has increasingly become a problem in recent years, leading many EDs and hospitals to try to formulate solutions to address the issue.

The Issue

While the issue certainly affects ED providers and staff, and is often referred to as “ED boarding,” it is important to realize that boarding is not an ED issue; it is a hospital and medical system issue. The root cause is a lack of access to appropriate level of care. This is not a facilities or infrastructure issue, but a flow issue.

Primary care physicians are overwhelmed with mandates to see increasing number of patients, pushing their schedules beyond the ability to see acute care issues in the office. These patients are then presenting to the ED with non-emergent pathology, increasing ED volume and crowding, limiting access to ED beds for those with emergent pathology.

The paucity of outpatient mental health care also leads to ED crowding in multiple ways. Patients are often unable to access outpatient treatment and subsequently enter crisis, requiring an ED visit. Additionally, this lack of outpatient psychiatric care impacts patients being discharged from inpatient psychiatric care. Patients cannot be discharged without a safe discharge plan, and if outpatient services are scarce, it takes patients longer to be discharged from inpatient care. This creates a block of access to inpatient beds for those patients actively in crisis, keeping these crisis patients in the ED.

Long-term care facilities and rehabilitation facilities also contribute to this access block. These facilities are often unable or unwilling to accept patients being discharged from the hospital on evenings and weekends. This block keeps patients who are ready for discharge and no longer need acute medical care in an inpatient bed, keeping other patients who need acute medical care stuck in ED beds.

Because the emergency department is open 24/7 and is often the initial point of access for medical care, the ED is the area that feels the most effect from these access issues. Because of the issues within the hospital and within the medical system as a whole, the ED becomes crowded and admitted patients end up boarding in ED beds, as there are no inpatient beds available.

The Effects

Here we highlight some of the data on the effects of boarding on patient outcomes. For the full review of these articles, click the black box “Detailed Dive into the Papers” at the bottom of this page.

Hip Fractures[1]

Older patients with hip fractures are at increased risk for under assessment and undertreatment of pain as ED census ad ED length of stay increase.

Asthma[2]

Crowding slows the initiation of treatment and time to discharge for asthmatic patients presenting to the ED, and further exacerbates the crowding issue

Sepsis[3]

ED crowding negatively impacts timely administration of IV fluids and antibiotics and the following of protocol-based care in the treatment of sepsis.

Delirium[4]

Prolonged time in the ED and care in hallway beds while in the ED had a direct correlation with the development of delirium while admitted to the hospital.

Abdominal Pain

Pain Management[5]

Crowding delays administration of pain medications for patients who present to the ED with abdominal pain.

CT Interpretation[6]

Crowding can lead to an almost two hour delay to CT interpretation, potentially delaying surgical management.

Chest Pain[7]

There is an association between worse outcomes of ACS and non-ACS based chest pain as crowding increases.

Pneumonia and PCI[8]

There is no correlation between crowding and delay to percutaneous coronary intevention (PCI). As crowding increases, turnaround time of CXR increases, and thus the time to diagnosis of pneumonia. This delay delays time to antibiotic treatment.

Patient Satisfaction

Admitted Patients[9]

Inpatients were not satisfied with the ED or aspects of their hospital care when the ED was crowded.

Discharged Patients[10]

Discharged ED patients are less satisfied when the ED is crowded.

Violence Towards Staff [11]

Crowding places staff at increased risk of violent events.

Medication Errors [12]

As the ED gets more crowded, providers are more likely to make medication errors.

Mortality

10 Day Mortality[13]

Patients who present during overcrowded periods have higher 10 day inpatient mortality than those presenting during non-crowded shifts.

2, 7, and 30 Day Mortality[14]

Patients who present during times of ED crowding have higher 2, 7, and 30 day mortality than those presenting during less crowded periods.

Length of ED Boarding and Mortality[15]

As patients board for longer periods in the ED, their in-hospital mortality, need for transfer to ICU, and hospital LOS increase.

Inpatient Mortality[16]

Patients presenting during crowded periods have higher mortality, total hospital LOS, and hospital cost than those presenting during non-crowded periods

Solutions

Again, this is not a facilities or infrastructure issue, but a flow issue. Expansions don’t fix the issue. Solutions need to focus on improving systems in the hospital and improving flow through all areas of medical care. It’s also important to consider the silo effect when looking for solutions. If people don’t feel the negative repercussions of their actions, they are unlikely to make changes. Some solutions can work on implementing systems in which groups and people within the system feel the impact of their actions.

Seven Day Per Week Hospital

If staffing and elective admissions are different on weekdays vs. weekend days there are self-imposed ebbs and flows of patient volume in the hospital. In order to smooth out the volume fluctuations, hospital staffing, elective surgical cases, and elective admissions need to be consistent across all days of the week.

Cincinnati Children’s Hospital was suffering from boarding issues and had planned a $130 million, 100 bed expansion. Instead of this expansion, the hospital smoothed its surgical schedule across all seven days and was able to drastically reduce boarding and forgo the expensive expansion [17].

Boston Medical Center suffered from such a severe boarding crisis that the hospital was on ambulance diversion 30% of the time. The hospital noted that most elective admissions happened towards the beginning of the week and this was correlated with time on diversion. After smoothing the elective admission schedule to be similar across all seven days of the week, ambulance diversion time was drastically decreased as flow was improved [18].

Hallway Patients

Emergency department staff and patients are all too familiar with the issues with caring for patients in the hallway due to the boarding. But what if the emergency department wasn’t the only place in the hospital where care took place in the hallway? Mount Sinai Hospital in New York City showed that if inpatient floors took limited numbers of hallway patients, flow in the emergency department was improved. One possible way to implement this change is to send admitted patients to the floor when their bed is assigned, whether the bed is clean or not. Now the floor staff feels the pressure to get that bed cleaned and get the patient out of the hallway. The Mount Sinai study found that 90% of the time when a patient was sent to the floor when the bed was assigned, the bed became ready within 1 hour. This is an example of the silo effect in action.

Improving Ancillary Staff

In Dr. Sanders’ example, the ED was overwhelmed on a Thursday night with 108 patients, 25 admitted patients, and more than 30 patients waiting to be seen and needed to go on ambulance diversion. This all stemmed from the fact that there was only one environmental services provider who was cleaning inpatient beds in the entire hospital. When more providers were brought in to clean beds, the ED was able to be decompressed. This exemplifies boarding being a flow issue as opposed to a facilities issue. Increasing the number of beds in a hospital will make no difference if there are not enough staff to ready those rooms for patient use. Ancillary staffing needs to reflect the needs of the hospital, whether that requires hiring more staff, optimizing schedules, or using surge staffing policies.

Morning and Weekend Discharges

Patients admitted to the inpatient floor at Maine Medical Center (MMC) have a half day shorter length of stay on average than patients who are admitted to the floor in the afternoon. Because of this, MMC has made a push for increased morning discharges, allowing for inpatients beds to be ready for patients from the ED when the ED census usually increases later in the day. MMC has used social workers and care coordinators to work on the logistics of discharge prior to the actual day of discharge in order to improve the efficiency of the discharge process.

Multiple studies have shown that the discharge rate on weekend days is often half of the discharge rate on weekdays. Often this is due to the inability to discharge patients to long term care or rehab facilities on the weekend. MPH Montefiore in New York City made efforts to make discharges and transfers to long-term care facilities even across all seven days. By increasing weekend discharges, the hospital was able to eliminate ED boarding, close a 30-bed unit, and save $70 million in the first year following this change.

We know that long-term care and rehabilitation facilities do not have the same staffing on weekends and during the evening/overnight that they do during weekdays, which often limits these facilities from accepting transfers at these times. We need to work with these facilities to find a system by which patients in the hospital who no longer need acute medical care can be transferred to these facilities at any time of the day or any day of the week.

Proactivity

There are some days that the ED will be overwhelmed just by native ED patients, and not by boarders. This is the nature of emergency medicine. On these days, the hospital and ED providers must be proactive to improve flow to help limit the impacts of boarding later in the day as access block develops. This requires Emergency Physicians and ED administration to represent the emergency department on hospital committees and with hospital decision makers. While boarding is an issue that ED providers primarily feel the impacts of, it is not our issue to face alone. We must communicate effectively with our colleagues throughout the hospital and the medical community to improve our systems to best serve our patients.

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Show notes written by Samuel Lloyd, MD

Peer reviewed by Jeffrey A Holmes, MD and Michael Burla, MD

References

[1] Hwang, Ula, Lynne D. Richardson, Tolulope O. Sonuyi, and R. Sean Morrison. “The Effect of Emergency Department Crowding on the Management of Pain in Older Adults with Hip Fracture.” Journal of the American Geriatrics Society 54, no. 2 (February 2006): 270–75. https://doi.org/10.1111/j.1532-5415.2005.00587.x.

[2] Pines, Jesse M., Anjeli Prabhu, Joshua A. Hilton, Judd E. Hollander, and Elizabeth M. Datner. “The Effect of Emergency Department Crowding on Length of Stay and Medication Treatment Times in Discharged Patients With Acute Asthma.” Academic Emergency Medicine 17, no. 8 (2010): 834–39. https://doi.org/10.1111/j.1553-2712.2010.00780.x.

[3] Gaieski, David F., Anish K. Agarwal, Mark E. Mikkelsen, Byron Drumheller, S. Cham Sante, Frances S. Shofer, Munish Goyal, and Jesse M. Pines. “The Impact of ED Crowding on Early Interventions and Mortality in Patients with Severe Sepsis.” The American Journal of Emergency Medicine 35, no. 7 (July 1, 2017): 953–60. https://doi.org/10.1016/j.ajem.2017.01.061.

[4] Singla, A., L. Sinvani, J. Kubiak, C. Calandrella, M. Brave, T. Li, T. Perera, K. Van Loveren, and L. Becker. “86 Emergency Department Hallway Bed Time Is Associated With Increased Hospital Delirium.” Annals of Emergency Medicine 74, no. 4 (October 1, 2019): S33–34. https://doi.org/10.1016/j.annemergmed.2019.08.090.

[5] Mills, Angela M., Frances S. Shofer, Esther H. Chen, Judd E. Hollander, and Jesse M. Pines. “The Association between Emergency Department Crowding and Analgesia Administration in Acute Abdominal Pain Patients.” Academic Emergency Medicine 16, no. 7 (2009): 603–8. https://doi.org/10.1111/j.1553-2712.2009.00441.x.

[6] Mills, Angela M., Brigitte M. Baumann, Esther H. Chen, Ke-You Zhang, Lindsey J. Glaspey, Judd E. Hollander, and Jesse M. Pines. “The Impact of Crowding on Time until Abdominal CT Interpretation in Emergency Department Patients with Acute Abdominal Pain.” Postgraduate Medicine 122, no. 1 (January 2010): 75–81. https://doi.org/10.3810/pgm.2010.01.2101.

[7] Pines, Jesse M., Charles V. Pollack, Deborah B. Diercks, Anna Marie Chang, Frances S. Shofer, and Judd E. Hollander. “The Association Between Emergency Department Crowding and Adverse Cardiovascular Outcomes in Patients with Chest Pain.” Academic Emergency Medicine 16, no. 7 (2009): 617–25. https://doi.org/10.1111/j.1553-2712.2009.00456.x.

[8] Pines, Jesse M., Judd E. Hollander, A. Russell Localio, and Joshua P. Metlay. “The Association between Emergency Department Crowding and Hospital Performance on Antibiotic Timing for Pneumonia and Percutaneous Intervention for Myocardial Infarction.” Academic Emergency Medicine 13, no. 8 (2006): 873–78. https://doi.org/10.1197/j.aem.2006.03.568.

[9] Pines, Jesse M., Sanjay Iyer, Maureen Disbot, Judd E. Hollander, Frances S. Shofer, and Elizabeth M. Datner. “The Effect of Emergency Department Crowding on Patient Satisfaction for Admitted Patients.” Academic Emergency Medicine 15, no. 9 (2008): 825–31. https://doi.org/10.1111/j.1553-2712.2008.00200.x.

[10] Tekwani, Karis L., Yaniv Kerem, Chintan D. Mistry, Brian M. Sayger, and Erik B. Kulstad. “Emergency Department Crowding Is Associated with Reduced Satisfaction Scores in Patients Discharged from the Emergency Department.” Western Journal of Emergency Medicine 14, no. 1 (February 2013): 11–15. https://doi.org/10.5811/westjem.2011.11.11456.

[11] Medley, Dylan B., James E. Morris, C. Keith Stone, Juhee Song, Thomas Delmas, and Kunal Thakrar. “An Association Between Occupancy Rates in the Emergency Department and Rates of Violence Toward Staff.” The Journal of Emergency Medicine 43, no. 4 (October 1, 2012): 736–44. https://doi.org/10.1016/j.jemermed.2011.06.131.

[12] Kulstad, Erik B., Rishi Sikka, Rolla T. Sweis, Ken M. Kelley, and Kathleen H. Rzechula. “ED Overcrowding Is Associated with an Increased Frequency of Medication Errors.” The American Journal of Emergency Medicine 28, no. 3 (March 1, 2010): 304–9. https://doi.org/10.1016/j.ajem.2008.12.014.

[13] Richardson, Drew B. “Increase in Patient Mortality at 10 Days Associated with Emergency Department Overcrowding.” Medical Journal of Australia 184, no. 5 (2006): 213–16. https://doi.org/10.5694/j.1326-5377.2006.tb00204.x.

[14] Sprivulis, Peter C., Julie-Ann Da Silva, Ian G. Jacobs, George A. Jelinek, and Amanda R. L. Frazer. “The Association between Hospital Overcrowding and Mortality among Patients Admitted via Western Australian Emergency Departments.” Medical Journal of Australia 184, no. 5 (2006): 208–12. https://doi.org/10.5694/j.1326-5377.2006.tb00203.x.

[15] Singer, Adam J., Henry C. Thode Jr, Peter Viccellio, and Jesse M. Pines. “The Association Between Length of Emergency Department Boarding and Mortality.” Academic Emergency Medicine 18, no. 12 (2011): 1324–29. https://doi.org/10.1111/j.1553-2712.2011.01236.x.

[16] Sun, Benjamin C., Renee Y. Hsia, Robert E. Weiss, David Zingmond, Li-Jung Liang, Weijuan Han, Heather McCreath, and Steven M. Asch. “Effect of Emergency Department Crowding on Outcomes of Admitted Patients.” Annals of Emergency Medicine 61, no. 6 (June 1, 2013): 605-611.e6. https://doi.org/10.1016/j.annemergmed.2012.10.026.

[17] Eugene Litvak , Harvey V Fineberg. “Smoothing the way to high quality, safety, and economy.” New England Journal of Medicine. 2013 Oct 24;369(17):1581-3. doi: 10.1056/NEJMp1307699. https://www.nejm.org/doi/10.1056/NEJMp1307699

[18] Rabin E, Kocher K, McClelland M, et al. “Solutions to emergency department 'boarding' and crowding are underused and may need to be legislated.” Health Aff (Millwood). 2012;31(8):1757-1766. doi:10.1377/hlthaff.2011.0786