A Cross-sectional Study of Emergency Department Boarding Practices in the United States

Abstract

Objectives: The median emergency department (ED) boarding time for admitted patients has been a nationally reportable core measure that now also affects ED accreditation and reimbursement. However, no direct national probability samples of ED boarding data have been available to guide this policy until now. The authors studied new National Hospital Ambulatory Medical Care Survey (NHAMCS) survey items to establish baseline values, to generate hypotheses for future research, and to help improve survey quality in the future.Methods: This was a cross-sectional, multistage, stratified annual analysis of EDs and ED visits from the National Hospital Ambulatory Medical Care Survey public use files from 2007 to 2010, a total of 139,502 visit records. These data represent the only national measure of ED boarding. The main outcome of interest was boarding duration for individual patient visits. Data analyses accounted for complex sampling design.Results: The national median boarding time was 79 minutes, with an interquartile range of 36 to 145 minutes. The prevalence of boarding for more than 2 hours among admitted patients was 32% (95% confidence interval [CI] = 30% to 35%). Average ED volume, occupancy, acuity, and hospital admission rates increased abruptly from the second to the third quartile of median boarding duration. The half of hospitals with the longest median boarding times accounted for 73% of ED visits and 79% of ED hospitalizations nationally. Thirty-nine percent of EDs (95% CI = 32% to 46%) reported never holding patients for more than 2 hours, but visit-level analysis at these EDs found that 21% of admissions did in fact stay in the ED over 2 hours. Only 19% of EDs (95% CI = 16% to 22%) used a strategy of moving admitted patients to alternative sites in the hospital during crowded times. Conclusions:In this national survey, ED boarding of admitted patients disproportionately affects hospitals with higher ED volumes, which also see sicker patients who wait longer to be seen, but not hospitals with higher proportions of Medicaid or uninsured visits. This finding implies that, unlike other quality measures, there is a negative volume-outcome relationship for timely hospitalization from the ED.ACADEMIC EMERGENCY MEDICINE 2014;21:497-503 © 2014 by the Society for Academic Emergency Medicine I ncreasing emergency department (ED) visits have caused rising apprehension in the medical community for over half a century, 1 and the trend in ED crowding continues unabated.2 A 2009 U.S. Government Accountability Office (GAO) report concluded that the most important cause of ED crowding is the lack of access to inpatient beds, leading to prolonged ED stays for admitted patients, often in ED hallways.3 These patients are considered to be "boarding" in the ED. Since the GAO report, there have been several

A Novel Clinical Protocol for Placement and Management of Indwelling Urinary Catheters in Older Adults in the Emergency Department

“…While ideally patients are transferred to inpatient units quickly, in many busy hospitals such as ours, patients board in the ED for significant time after admission with changing clinical courses, yet with the same nursing staff delivering care. 30,31 Implementation. We introduced the protocol to EM providers, including attending physicians, resident physicians, midlevel providers, and nurses, with a 20-minute scripted slide presentation (July through August 2013) conducted during regularly scheduled staff meetings and in-service sessions.…”

Uniting emergency and inpatient clinicians across the ED–inpatient interface: The last frontier?

“…Patients requiring emergency admission to hospital are at approximately sixfold higher risk of death in hospital than patients undertaking elective admission . There is significant observational evidence that delayed transfer to inpatient wards for patients requiring emergency admission is associated with an estimated 20–30% increase in inpatient mortality …”

“…EDii dysfunction, manifesting as increased wait times and large numbers of boarding patients in the ED awaiting inpatient beds, creates difficulties for the ED (in terms of overcrowding and delivery of ongoing care), and for the inpatient teams (in terms of patient visibility and impaired ability to provide definitive inpatient care). These difficulties impact on the quality and efficiency of care across the whole hospital …”

“…The scale of the EDii worldwide is significant with approximately half of all inpatient admissions to hospital in developed countries occurring via the EDii . In many smaller hospitals, the majority of patients entering hospital do so via the EDii .…”

Emergency boarding: An integrative framework for analyzing causes and seeking solutions

“…[1] This issue has been discussed extensively in regards to EDs across the United States, [2] but the problem manifests itself worldwide. [3] Causes of the ED crowding are multifactorial, [4] and are often interrelated.…”