Hospitals continue to leave their heads in the sand even as the evidence of the danger of ED boarding mounts
The evidence continues to pile up confirming that boarding patients in the ED while they wait for an inpatient bed is bad for patient care and bad for hospital business. So why is boarding still so prevalent, and why are hospitals so reluctant to take action to alleviate this practice?
The Facts about Boarding
The hard evidence has been mounting that ED boarding is not good for patient care. Singer, et al, in a multicenter study, showed that, when boarding times in the ED are from less than two hours to more than 24 hours, adjusted mortality increased from 4.9% to 6.3% in suburban hospitals, but not in urban hospitals.1 Chalfin, et al reported that patients boarded in the ED for more than six hours before being admitted to the ICU typically spent one more day in the hospital, and had a hospital mortality rate of 17.4% versus 12.9% for patients who were boarded in the ED for less than six hours. These patients also had higher ICU mortality.
ED boarding is also one of the main factors causing ED crowding. Sun, et al noted a clear association between ED crowding and an increase in chance of death, hospital stay, and costs per admission, in staggering stats: an estimated 300 additional inpatient deaths, 6,200 excess hospital days, and $17 million in additional costs in 187 California hospitals in a single year.2 Similar studies have reported similar impacts of ED crowding on cardiovascular outcomes in chest pain, preventable medical errors, undesirable events, ED length of stay, and patient satisfaction.
In this face of the facts, why do hospitals still allow ED boarding? To answer the question, we have to break down why boarding occurs and separate fact from fiction.
Boarding patients in the ED facilitates the admission of elective patients into hospital inpatient services, which likely will produce more net revenue for hospitals than ED admissions. The basic assumption here is simple: since the boarded ED patient already has been “committed” to a hospital admission, hospitals can leave inpatient beds open for direct admits for elective — mostly surgical or procedural — services by members of the medical staff. The assumption is also that these patients are more likely to have good insurance coverage and pre-authorized plan commitments to pay. It is likely these calculations depend principally on the hospital’s and ED’s payer mix (the ED usually has a poorer payer mix), the frequency with which procedure-oriented medical staff affect such direct admissions, and the overall mission of the hospital.
Surgical specialists prefer not to disrupt their elective surgical schedules by having the hospital line up ED surgical admissions for the OR on an unscheduled, urgency basis.
Inpatient staff often object to boarding patients in the hallways of the inpatient floor. So do fire marshals, though they rarely complain about patients being managed in the ED hallway. Many physicians and nurses believe that keeping these patients in the ED, where they are under the eyes of ED staff, is safer than sticking them in the hallways of hospital floors and units. In addition, some hospitalists prefer to conduct their new admission workups in the ED, where nursing staff and consulting specialists are more readily available to assist, and additional diagnostic testing in the ED often gets priority over inpatient orders for testing.
Many systems issues, such as delays in transporting admitted patients from the ED to the floor, delays in cleaning and prepping inpatient rooms to accept these admitted patients as well as high standing occupancy rates for inpatient beds all contribute to ED boarding.
Myths vs. Evidence
With this complex combination of factors contributing to ED boarding, it’s not surprising that hospitals are slow to find solutions. But do the assumptions made by hospital administrators about revenues and the difficulties of mitigating these other factors warrant continued resistance to addressing the problem of ED boarding?
First, let’s look at the hospital financial considerations around ED boarding. In 2009, Henneman published a study3 that showed that admissions originating in the ED resulted in higher daily contribution to margins ($769) than direct and transfer admissions ($595). However, in the same Annals issue, Pines and Heckman published an article4 that reached the exact opposite conclusion in the relative profitability of direct vs. ED admissions.
Thus, the profit rationale for prioritizing ED admissions over elective admissions to relieve ED boarding may work in some hospitals, and not others. In 2011, Pines published an analysis5 and simulation model that found that when hospital occupancy reached a certain point, a reduction of 5% of scheduled admissions for that day would lead to an increase in hospital revenue of $7,418, through a cascade of positive impacts from a reduction in ED boarding times. Their conclusion: “A small adjustment in scheduled admissions now and then could have a big impact on both patient health and the hospital’s bottom line.”
The assumption that reducing ED boarding requires sacrificing inpatient beds delegated to scheduled admissions was successfully challenged in a 12-year study in Spain of multi-faceted changes in hospital operations policy designed to deliver efficient patient flow, anticipate acute inpatient demand, and reformulate traditional inpatient care6. The study showed a 38.4% decrease in prevalence density of boarded ED patients, while increasing monthly ED and scheduled admission, and decreasing hospital occupancy rates. Such ‘efficient use’ strategies might include coordinated bed management; redistributing elective surgical admissions to days where there is less demand for ED admissions; development of admission pending units and discharge lounges, and inpatient hallway boarding in ‘full capacity protocols.” It would seem that efficient management of beds in hospitals could address surgical specialists’ issues with OR schedules without relying on ED boarding, though it is likely that some flexibility by those specialists could result in even better outcomes.
There is some controversy over the use of inpatient hallways to accommodate boarded patients waiting for their designated inpatient bed, partly because it is not clear that this always works to mitigate ED boarding7. However, Viccellio, et al reported1 in 2009 that moving boarded patients to inpatient hallways during high ED census periods did not result in any increase in in-hospital mortality (in fact, mortality seemed to be reduced).
What about patient preference? Surely, the preference of the admitted patient who must be boarded for inpatient hallway vs. ED hallway should be considered. Chad Garson’s survey of boarded patients2 in 2008 revealed that when hospitals are at full capacity, patients would rather board in inpatient hallways until their room is available.
Upending the System
Let’s assume that you are convinced by these and many other published studies that ED boarding is something that should be addressed in every facility where boarding is common. (Frankly, you have to be willing to suspend reality to believe there aren’t enough reasons to upend the status quo in such hospitals, regardless of the moaning and groaning that might ensue.) What will it take to get a hospital, its medical staff, nursing and utilities management people to work in conjunction to tackle this problem?
In Vancouver, in 2005, emergency physicians were so frustrated by their inability to get their hospital to solve this problem that they wrote a ‘no-confidence (in their hospital) letter’ which stimulated heated public and professional debate in British Columbia, but no real change in policy, despite a $7 million campaign to address the problem.
In California, the state chapter of ACEP struggled for years to get legislation passed to keep track of, and publish, the incidence of dangerous ED overcrowding and boarding, against resistance from hospitals across the state.
There are advocates for involving various federal department and agencies in this issue — including DHHS; the National Highway Traffic Safety Administration; the Joint Commission on Accreditation of Hospitals and Health Systems; the National Committee for Quality Assurance; Congress (oh, please); CDC, and even the Department of Homeland Security — in an effort to give impetus to the reduction or elimination of ED boarding. Some advocates for change maintain that we need to wait for universal health care or total hospital payment reform to mitigate the financial factors that result in ED boarding, while others believe that rigorous pay for performance criteria must come into play for real reform to take place.
I have come to the conclusion that this is a threshold process. At the individual hospital (or hospital system), there will be passive resistance to dealing with ED boarding, from all the pertinent nursing, physician, and administration stakeholders for a period of time, until the tipping point is reached. As hospital and physician business models evolve from FFS to at-risk reimbursement, or from non-aligned to integrated services; expect a sudden reversal and demands for instant transformation of the institution as the threshold (fueled by consumer, regulator, local employer, and health plan demand) is reached. Similarly, the hospital industry as a whole will resist addressing ED boarding until the threshold is reached (fueled by payment reform, ACO penetration, and government payer initiatives), and then the market shift will accelerate and carry the main body and even the holdouts over.
Pressure by legislatures, regulators, payors or oversight agencies can make a difference in the effort to reform ED boarding, but the tipping points will vary from hospital to hospital, depending on the efficacy of the pressure and the attitudes of hospital administrators. As more and more hospitals address ED boarding successfully, reluctance will transform into inclination. As ED physicians, we also can play a major role in this precipitating this transformation. ED Boarding is a problem worthy of your involvement!
1. The Association Between Length of Emergency Department Boarding and Mortality: A Multicenter Study, Singer AJ, Thode Jr HC, Viccellio P, Synnestvedt M, Weiner MG, Pines JM/Stony Brook University, Stony Brook, NY; University of Pennsylvania School of Medicine, Philadelphia, PA; George Washington University, Washington, DC, Ann Emerg Med, (Vol. 6, No. 3, Sept 2010).
2. Sun BC, Hsia RY, Weiss RE, et al. Impact of emergency department crowding on outcomes of admitted patients. Ann Emerg Med. 2013;61:605-611.
3. Emergency Department Admissions Are More Profitable Than Non–Emergency Department Admissions Philip L. Henneman, Michael Lemanski, Howard A. Smithline, Andrew Tomaszewski, Janice A. Mayforth, Ann Emerg Med, 1 February 2009 (volume 53 issue 2 Pages 249-255).
4. Emergency Department Boarding and Profit Maximization for High-Capacity Hospitals: Challenging Conventional Wisdom Jesse M. Pines, John D. Heckman, Ann Emerg Med 1 February 2009 (volume 53 issue 2 Pages 256-258)
5. The Financial Consequences of Lost Demand and Reducing Boarding in Hospital Emergency Departments Jesse M. Pines, Robert J. Batt, Joshua A. Hilton, Christian Terwiesch, Ann Emerg Med 1 October 2011 (volume 58 issue 4 Pages 331-340)
6. Eliminating Inpatient “Boarding” for Emergency Patients While Maintaining Elective Throughput In Crowded Tertiary Care Hospitals: A Twelve-Year Pre-Post Multifaceted Intervention Study Corbella X,Ortiga B, Ferre C, Salazar A/Bellvitge University Hospital, L’Hospitalet de Llobregat, Barcelona, Spain, Ann Emerg Med, (Volume 56, No.3, September 2010).
7. Perceptions of Emergency Department Crowding in the Commonwealth of Pennsylvania Jesse M. Pines, MD, MBA, MSCE,* Joshua A. Isserman, MS, and John J. Kelly, DO, West J Emerg Med. 2013 February; 14(1): 1–10.
8. Viccellio A, Santora C, Singer AJ. et al. The association between transfer of emergency department boarders to inpatient hallways and mortality: a 4-year experience. Ann Emerg Med. 2009;54:487–491.
9. Garson, Chad, et al. Emergency Department Patient Preferences for Boarding Locations When Hospitals Are at Full Capacity, Ann Emerg Med, January 2008 (volume 51, issue 1, pages 9-12e3.
Myles Riner, MD is the 2010 winner of ACEP’s Colin Rorrie Award for Excellence in Health Policy; Author of the blog Ficklefinger.net