Emergency Department Patient Boarding and Overcrowding

Introduction: The ED Boarding Crisis

Emergency department (ED) crowding is a nationwide crisis that affects the efficiency and quality of patient care (Sox, Burstin, Orav, et al., 2007). A major contributor to patient overcrowding is the boarding of admitted patients in the ED. Time that could be used to treat patients who are waiting to be seen is instead consumed by the admitting process — a pattern typical of overcrowded EDs. The overcrowding of EDs risks patient safety, and alternatives to this practice must be examined.

Holding admitted patients in EDs has long been recognized as harmful to patient flow, but a growing body of research now shows that it also directly harms patients. There is significant evidence demonstrating that ED crowding caused by boarding is responsible for poor patient outcomes (Sox, Burstin, Orav, et al., 2007). In many hospitals, it is the physicians and nurses who care for these boarders in the ED; therefore, any risk taken falls squarely on their shoulders. This not only decreases efficiency but can also give rise to lawsuits ("Lawsuits may arise," 2008).

Patient Safety Risks and Clinical Outcomes

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

Many studies have been devoted to examining the causes and consequences of boarding admitted patients. These studies argue that patient boarding demonstrates the dangers patients may face in an overcrowded ED. Research has shown a connection between patient mortality rates and crowding, attributable to delays in care caused by ED overpopulation. Unfortunately, these findings have not sufficiently compelled the healthcare industry to implement policies that reduce patient risk and alleviate crowding (Garson, Hollander, Rhodes, et al., 2007).

ED waiting times and crowding are directly associated with a higher probability of patient dissatisfaction. Efforts to reduce ED crowding will not only improve hospital mortality rates but also patient satisfaction with overall hospital care. There are numerous ways in which a hospital can address its ED overcrowding challenges.

Communication Failures and Handoff Dangers

There are concerns within the current ACGME framework regarding duty hour restrictions in the ED, which may have unintentionally fragmented both the educational environment and the patient care milieu (Holliman, Wuerz, Kimak, et al., 1995). Multiple studies show that a more hands-off approach to patient care — such as that common in busy EDs — can result in less continuity of care across the broader healthcare facility. This concern is heightened when patient overcrowding occurs in the ED and care transitions, which are recognized as inherently dangerous, place patients at risk for medical error (Sox, Burstin, Orav, et al., 2007).

Studies focused on ED patients illustrate how poor handoff communication contributes to boarding-related patient safety threats for both boarders and non-boarding emergency patients alike. Emergency physicians tend to be more hands-off with their patients, and this results in poor communication practices and conflicting communication expectations — barriers that exacerbate physicians' information ambiguity. Such ambiguity can lead to negative patient outcomes.

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

Conclusion

Hospitals have long struggled with the problem of facilitating patient transfer from the ED to inpatient care due to ED overcrowding ("Take the lead," 2008). A central problem is the management of patient-bed turnaround. When bed cleaning and tracking are well mapped, patient admission becomes far less complex and waiting periods decrease. Discharge delays compound this problem further. ED overcrowding is not only an unpleasant and frustrating experience for patients — requiring them to endure long hours before receiving treatment — it is also placing their health at serious risk. Alternative approaches to patient boarding must be pursued to maximize the efficiency of the emergency department and to safeguard the patients it serves.

References

Lawsuits may arise from ED 'boarding' practice: there's proof it harms patients… Part 1 of a two-part series. (2008). ED Legal Letter, 19(12), 136–141.

Take the lead in helping to remedy ED crowding, diversion, boarding: efficient patient throughput is the key. (2006). Hospital Case Management, 14(9), 129–131.

Garson C, Hollander JE, Rhodes KV, et al. (2007). Emergency department patient preferences for boarding locations when hospitals are at full capacity. Ann Emerg Med.

Greene J. (2007). Emergency department flow and the boarded patient: how to get admitted patients upstairs. Ann Emerg Med. 49, 68–70.

Holliman CJ, Wuerz RC, Kimak MJ, et al. (1995). Attending supervision of nonemergency medicine residents in a university hospital ED. Am J Emerg Med. 13, 259–261.

Richardson DB. (2006). Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust. 184, 213–216.

Sox CM, Burstin HR, Orav EJ, et al. (1998). The effect of supervision of residents on quality of care in five university-affiliated emergency departments. Acad Med. 73, 776–782.