Hospital flow inefficiencies are the real culprit behind patient boarding in the emergency department, according to a report in Health Affairs released on Aug. 6.
Most hospitals have implemented just two of nine measures proven to reduce ED boarding, according to the report. "Boarding" (keeping admitted patients in hallway beds in the emergency department for more than 2-4 hours because an inpatient bed is not available) has been shown to increase in-hospital mortality and length of stay (Acad. Emerg. Med. 2011;18:1324-9). The practice also reduces hospital income, increases patients’ risk for hospital-acquired infections, and contributes to lapses in routine care and medications.
Proven strategies to address the problem "are grossly underused," wrote Dr. Elaine Rabin, of Mount Sinai School of Medicine in New York, and her coauthors (Health Affairs 2012 Aug. 6 [doi:10.1377/hlthaff.2011.0786]).
The problem has escalated over the last decade. A 2001 survey "found that one in five patients in U.S. emergency departments were boarding, and three in four emergency departments were boarding at least two inpatients" (Ann. Emerg. Med. 2003;42:167-72). A 2003 report "found that nine out of ten hospitals reported some degree of boarding," with 20% of hospitals boarding patients for an average of 8 hours. Most recently, a 2010 survey showed that 85% of hospitals had boarded patients the previous week (Acad. Emerg. Med. 2010;17[suppl s1]:s90; abstract 260).
Boarding substantially reduces ED capacity. In a study done at one community hospital in Pennsylvania, moving patients who were admitted from the ED to inpatient beds within 2 hours would have increased ED capacity by 10,397 hours (433 days) over the 1-year study period (Acad. Emerg. Med. 2007;14:332-7).
Nowhere to Go
"Crowding is not an emergency department–based problem. Rather, it is a symptom of dysfunction in interrelated parts of the broader health care system," wrote Dr. Rabin and her coauthors.
Although it is commonly believed that "crowding results from uninsured patients’ seeking nonemergency care in the emergency department," studies have shown that "the main driver of emergency department crowding is patient outflow obstruction: an inability to move admitted patients to inpatient beds in a timely manner," they wrote.
Another assumption is that hospitals are swamped with too many patients, but boarding actually begins when a hospital is at 80%-85% of capacity, "partly because specified bed types ... fill earlier than other types," Dr. Rabin and her colleagues said. The common practice of reserving inpatient beds for specified categories of patients, such as postelective procedure patients or isolation cases, or to maintain a "geographic" bed plan (similar patients grouped together to match specialized nurses with patients), can mean that patients linger in the ED despite available beds. "Introducing some flexibility in the geographic pooling of beds decreased emergency department boarding times" by 50% and increased hospital revenue by 1% at one hospital (Oper. Res. 2009;57:261-73).
ED crowding and boarding may substantially reduce hospital income; for example, in the 2007 study of the Pennsylvania community hospital, boarding resulted in an estimated loss of almost $4 million in net revenue.
But exactly how much revenue might be lost because of ED crowding is still under debate; ED patients are more likely to be uninsured than are elective admissions, so crowding may have the unintended effect of reducing the number of patients who can’t pay for care. In addition, the tasks involved in assessing and stabilizing ED patients are reimbursed at a lower rate, compared with scheduled surgical procedures.
On the other hand, "low patient satisfaction related to long wait times and boarding may also drive well-reimbursed business away," the authors pointed out.
Strategies That Work
Addressing the bottlenecks does not have to mean adding beds. On the contrary, "improved use of existing beds should be the first-line strategy," Dr. Rabin and her coauthors said.
Evidence supports the use of these nine measures:
"Boarding is a systemwide problem."
• Moving ED hall patients to inpatient hallways. Patients prefer the quieter hallways, the nurse-patient ratio is usually lower, and the ED reclaims the beds for more incoming patients.
• Smoothing surgical schedules. By decreasing demand at peak times, this measure alone has been shown to "nearly eliminate boarding" at some hospitals, according to the report.
• Scheduling cardiac catheterizations for early in the day.
• Actively managing bed use. Approaches include making information on free beds quickly available via a computerized system, and use of a bed coordinator or "bed czar."
• Setting up a discharge lounge. Patients can be moved out of their beds into another area to await the completion of their discharge paperwork.