Emergency department patient boarding practices

ED Patient Boarding |

Emergency Department Patient Boarding

Emergency Department (ED) crowding is a nationwide crisis which affects the efficiency and the quality of patient care (Sox, Burstin, Orav, et al., 2007). A huge contribution to patient over-crowding is the boarding of admitted patients in the ED. An alternative use of time which is lost in the admitting of patients is used to treat patients who are waiting to be seen; this is seen typical in over-crowded EDs. The overcrowding of EDs result in risking patient safety and alternatives to this should be observed.

Holding admitted patients in EDs always was known to be bad for patient flow, but there is a growing body of research showing that it also harms patients. There is significant evidence which demonstrates that ED crowding due to boarding is responsible for poor outcomes (Sox, Burstin, Orav, et al., 2007). In many hospitals, it is the physician and the nurses who care for these boarders in the ED, therefore any risk which is taken falls squarely in their hands; therefore, not only does it decrease efficiency, but lawsuits may also arise ("Lawsuits may arise," 2008).

Ongoing ED overcrowding, the frequency and duration of ambulance diversions as well as the lack of available beds in the hospital are factors which lead to a limitation in care as well as access within the healthcare facility ("Take the lead," 2008). Counties typically have an average of three acute care hospitals and more than 19,494 hours of ambulance diversions in Emergency Medical Systems (EMS); because of this, locating an ED that could accept patients via ambulance is a challenge for EMS staff.

Research has suggested that increased supervision may improve patient safety (Richardson, 2006). Specific to the ED, one study showed that direct supervision of residents in the ED is significantly associated with better compliance with guidelines, regardless of level of training, but was unable to show an association with patient satisfaction. Another study identified direct supervision of non-EM residents rotating in the ED as resulting in "frequent and clinically important changes in patient care" (Richardson, 2006).

There are concerns within the current ACGME in regards to the duty hour restrictions in the ED which may have caused unintended causes of fragmenting the educational and patient care milieus (Holliman, Wuer, Kimak, et al., 1995). This is in connection to multiple studies which show that a more hands-off type of patient cares, such as in a busy ED, can result in less continuity of care in the general healthcare facility. This concern arise when there is patient overcrowding in the ED and transitions in care are recognized to be dangerous and it places patients at risk for medical error (Sox, Burstin, Orav, et al., 2007). Studies which focus on ED patients illustrated how poor handoff communication contributes to boarding-related patient safety threats for boarders and emergency department patients alike. Emergency physicians are seen as more hands-off with their patients, and this results in poor communication practices and conflicting communication expectations, presented barriers that exacerbated physicians' information ambiguity. This type of patient ambiguity can result in negative patient outcomes.

In fact, a cohort of internal medicine residents report that failure to identify important information during sign-out is one of the top five suboptimal patient care practices. In their 2008 "National Patient Safety Goals" report, the Joint Commission reported that nearly 70%of sentinel events arose from communication errors, and of these, 50% occurred during handoffs of patient care. This prompted the specific Joint Commission recommendations to address the sign-out process in an attempt to set a standard for improvement and prevention of medical error.

Many studies have been devoted to studying the sciences of the causes and consequences of the boarding of admitted patients; these studies argue that patient boarding demonstrates the dangers patients may face when being in an overcrowded ED. Studies have shown that there is a connection with patient mortality rates associated with crowding; this is because of the delay in care due to overpopulation in the ED. Unfortunately, these findings have not so much compelled the healthcare industry to implement policies to reduce the risks patients may face and to ameliorate crowding (Garson, Hollander, Rhodes, et al., 2007).

Emergency Department waiting times and their crowding are directly associated with higher probability of patient dissatisfaction. Efforts to reduce ED crowding will not only improve hospital mortality rates, but also patient satisfaction with the overall hospital care. There are numerous ways in which a hospital can manage their ED overcrowding dilemmas.

There needs to be combined performance efforts with the hospital staff which can decrease in ED overcrowding; these plans of action should help healthcare facilities to meet their goals in ensuring access to care for community members as well as improving the performance of the hospital's ability to increase the number of patient admissions while decreasing patient days and length of stay (Richardson, 2006).

The hospital should facilitate patient prioritization and bed assignment in a coordinated and established fashion (Greene, 2007). An implemented admission and discharge center should be in full action; this will allow staff to begin the admission process as soon as a physician indicates the need for admission regardless of the patient's location. Care should be provided for those patients who will need care for less than twenty four hours, and also leave inpatient beds open to those who are more acutely ill. An established and dedicated Admission Nurse should be in charge of facilitating patient admission, this will decrease the amount of time needed for admission (Garson, Hollander, Rhodes, et al., 2007).

Technology-wise, there should be an implemented bed tracking computer program which can streamline and measure the bed turn-over process (Greene, 2007). Along with this, a 24/7 hospitalist program should be intact; efficiently managing the medical care of patients, decreasing the length of stay and improving clinical outcomes. Another implementation should be included -- an intensivist program. This will provide a more efficient admission and medical management process for those patients who are critically ill to improve their clinical outcomes.