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'Boarded' patients prefer halls on inpatient floors
Proximity of specialists puts them more at ease
Harried ED managers who are trying their best to get patients upstairs apparently have some strong allies in this battle: The patients themselves.
In a new study of emergency patient preferences for boarding locations, just published online by Annals of Emergency Medicine,1 admitted patients said they prefer to board out of the emergency department and in inpatient hallways by a margin of three to two.
"I was actually surprised that even more patients more didn't prefer inpatient hallways over the ED," says lead author Jesse Pines, MD, MBA, MSCE, an attending ED physician in the Hospital of the University of Pennsylvania in Philadelphia. The percentage in the study was 59%. "The main reason for putting them upstairs is that it locates them closer to inpatient providers, unclogs the ED so they can see new patients, and unburdens ED nurses from having to care for these patients."
The study, conducted over a four-week period, surveyed 431 admitted patients. During the study period, the median weekly ED boarding time ranged from 8½ hours to just over 12 hours.
The percentage of patients who preferred inpatient hallways also seemed low to Peter Viccellio, MD, FACEP, vice chairman of the Department of Emergency Medicine, School of Medicine, and clinical director of the Emergency Department at Stonybrook (NY) University Hospital. "Our bed coordinator personally interviewed our patients, and 95% said they preferred being upstairs," he reports.
Boarding vs. holding
Viccellio suggests the difference in responses could be due to the status of the patients in Philadelphia and Stonybrook.
"In the study, Penn is not boarding the patients but holding them [in the ED]," he explains. "When the patients were asked their preference, they were asked to compare what they were experiencing at the time with something they had not yet experienced."
At Stonybrook, the survey took place after patients started boarding upstairs in 2001, he says. "People were worried about the impact on patient satisfaction, so the bed coordinator collected responses from several hundred patients," Viccellio explains.
What else did the surveys show? "Patients preferred [being boarded upstairs], and they got better care: The nurse/patient ratios are better, it's a more peaceful and quiet environment, and nurse and physician specialists are there," Viccellio says. In short, he notes, patients simply get more attention.
An 'institutional thing'
Viccellio has a short list of issues he considers unequivocal. Among them are the following: The ED must continue to function as patient loads increase. "We must get boarded, admitted patients out of the ED," he says. "Second, patients prefer to go upstairs, and they get better care."
The challenge of handling increasing patient loads is not solely an ED issue, Viccellio says. "It's an institutional thing," he says. "It makes the institution ask how we can best take care of all our patients — not just the ones who are lucky enough to show up in time for a bed."
The idea of moving boarded ED patients upstairs flowed from the decision that it was unsafe to continue to accumulate patients in the ED, Viccellio says. "Let's say you have 10 units, all identical, all full," he poses. "Now, you have 20 extra patients: Do you send them all to one unit?"
Change is hard
As Viccellio's experience shows, getting such a change in place can be a challenge. "I had been part of a group trying to improve inpatient processes, but in spite of well-intentioned efforts, nothing seemed to change," he recalls. "I kept suggesting it, but everyone knew it was 'against the rules.'"
However, when he researched health department regulations, Viccellio discovered there were no such rules. He even got the state's health department to write a letter to all area hospitals saying that — and adding that boarded patients should be spread out among departments. This cleared the way for change.
"In order to make this change, you would have to go to hospital administration, because it would require a change in policy, Pines says. How do you make the case? "In addition to the care benefits, this is where patients would rather be; so if we are going to use the patient-centered model of health care going forward, these kinds of questions should be asked, and we should go along with where they want to be," he explains.
In terms of cost, he concedes, it could appear to the administration to be more costly because you have to staff the beds upstairs. "You can overcome that objection in terms of overall reimbursement," he says. "In addition, uncrowding the ED can only improve revenue by reducing the percentage of patients who leave without being seen and by providing better service for existing patients by moving them more quickly through the system."
Viccellio confirms this last point. "We don't go on diversion," he notes. "Some studies say for every patient you board, you add 15 minutes, but our data show we add only one minute."
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