ER Boarding Change Emergency Department

ER Boarding Change

Emergency Department Patient Boarding: Designing and Implementing Changes in Practice

Emergency department boarding has been associated with greater inefficiencies in the provision of care to patients as well as a generally lower quality of care when overcrowding occurs (Bair et al. 2010; McCarthy et al. 2009). Rather than being used as an area where patients are quickly assessed, stabilized, and moved to other hospital departments or returned to their homes, as is the reason for the creation of emergency departments and the continued best practice perspective for these departments, many emergency departments are being used essentially as an expansion of intensive care units (Annals of Emergency Medicine 2008). This means that overcrowding in emergency rooms and departments due to the boarding of patients is in most cases a response to the overcrowding of the hospital generally and the intensive care unit specifically (AEM 2008; Zimmerman 2004).

Just as there is a high degree of clarity as to the source of the problem, there is a clear way forward towards developing an effective means for correcting the misuse of emergency departments and greatly reducing the problems associated with overcrowding. Rosswurm and Larrabee (1999) have developed a model for designing and implementing changes to practice based on evidence found in clinical research, and this model can easily and directly be applied to the problem of overcrowding brought on by inpatient boarding in emergency departments. In this way the quality of care and focus of purpose can be returned to EDs.

By following the six steps laid out by Rosswurm and Larrabee (1999), this paper will provide a design and implementation plan for addressing the issue of overcrowding in emergency departments due to patient boarding. This will enable hospitals to develop action plans for changing their current practices and standards for admitting patients for inpatient treatment via the emergency department, and will also empower nursing and medical staff to make appropriate and effective decisions to limit crowding and supply a generally greater efficacy and quality of care (Hospital Care Management 2006). Methods for evaluating the success of this implementation plan and the new practices it leads to will also be detailed, providing a reliable platform with which to begin the transformation of current boarding practices in emergency departments and a means for assessing this transformation.

Model for Change

The first step in Rosswurm and Larrabee's (1999) model for change to evidenced-based practice is assessing the problem to determine the need for change. Overcrowding in emergency departments negatively affects patients, nurses, physicians, and support staff, meaning that all hospital stakeholders benefit from a reduction in overcrowding (Bair et al. 2010; McCarthy et al. 2009; Zimmerman 2004). Internal data shows that emergency departments are frequently used as extensions of inpatient intensive care units, which leads to a great deal of the overcrowding observed (AEM 2008). Comparing this to external data regarding the quality of care and health outcomes observed by ED patients shows the negative impact that ED boarding has on ED efficacy (HCM 2006).

Given this assessment, it should be quite clear that the practice of ED patient boarding needs to be corrected in order to restore the quality and efficacy of care in EDs to a more respectable level. The next step in accomplishing this, according to Rosswurm and Larrabee (1999), is to link the observed issues to potential interventions and outcomes, including indicators of those outcomes. Emergency departments should be used solely to assess and stabilize patients; after this has been accomplished, patients should either be discharged or admitted through a different department/area of the hospital, as appropriate (AEM 2008). This is the intervention that makes will create the greatest gains in the efficacy and quality of emergency care, as it directly addresses the source of overcrowding and provides a renewed focus to hospital staff working in the emergency department (AEM 2008).

Once an intervention has been tentatively selected, Rosswurm and Larrabee (1999) recommend a synthesis of the available literature and data on the subject. There is an abundance of current literature on the topic, and the different studies and perspectives that have examined this issue come to remarkably similar conclusions -- overcrowding specifically and inpatient boarding generally in emergency departments has been definitively linked to reductions in the quality of care, increases in mortality after certain periods, increases in the number of patients that leave without being seen, and a reduced efficiency in the ED as a whole (Bair et al. 2010; McCarthy et al. 2009; Zimmerman 2004). These studies have also shown that a reduction in boarding numbers and crowding can eliminate or reduce these problems.

After all of these considerations, the fourth step in Rosswurm and Larrabee's (1999) model for change is to design the actual changes to practice that should be implemented. In this case, this requires few additional resources other than learning materials for hospital staff to acquaint themselves with new procedures and practices -- there is no equipment necessary, and supplies used by the emergency department should actually decrease pretty much across the board as patients are more quickly sent to other departments of the hospital after stabilization (AEM 2008). The design, then, is one that is purely procedural, and should consist of clear triage and stabilization practices that effectively assess patients and determine the appropriate continuation of their care, whether that be on an outpatient basis or an inpatient basis in a non-emergency department of the hospital.

Actually implementing the designed changes is the next step in the model developed by Rosswurm & Larrabee (1999), and is again a matter of procedural change brought about training and education regarding new policies and standards. A specific hospital with a demonstrable overcrowding issue brought about by emergency department patient boarding should be selected for a pilot study, so that the results of the implemented changes can be rendered as clear as possible (with more dramatic change equating to clearer results, generally speaking). It has already been established that increasing the capacity for emergency department boarding is not really an effective solution to the observed problems, meaning that an elimination of the problem at its root should be more effective (Zimmerman 2004).