Ambulatory Care Quarterly: Is 'boarded' care viewed as substandard?
Is 'boarded' care viewed as substandard?
Your ED patient's bad outcome might have nothing to do with the fact that he or she was held in the hallway while awaiting an inpatient bed. However, it could impact the outcome of subsequent litigation against the ED.
"I know that patients and families think that 'boarded' care is substandard to inpatient care. I would think the jury may think the same," says Matthew Rice, MD, JD, FACEP, an ED physician with Northwest Emergency Physicians of TEAMHealth in Federal Way, WA.
Sandra Schneider, MD, professor of emergency medicine at University of Rochester (NY) Medical Center, says that the best way to reduce liability is to "get the admissions out of the ED as soon as possible. We know that boarding is the number one patient safety concern of emergency physicians." She believes risk increases with very prolonged boarding times as the patient is handed off to subsequent providers who often are not aware of the details of the patient's case.
According to the Centers from Disease Control and Prevention report "Estimates of Emergency Department Capacity: United States, 2007," there are 500,000 ambulance diversions annually in the United States, and 62.5% of EDs board admitted patients for more than two hours. Andrew Garlisi, MD, MPH, MBA, VAQSF, medical director for Geauga County (OH) EMS and co-director of University Hospitals Geauga Medical Center's Chest Pain Center in Chardon, OH, says the report contains "few, if any, surprises to nurses and emergency physicians who regularly work in the trenches."
Stop dangerous practices
S. Allan Adelman, JD, a health law attorney with Adelman, Sheff, & Smith in Annapolis, MD, says the most dangerous practices regarding ED boarding involve "anything that makes continuous supervision and monitoring of the patients more difficult."
Adelman isn't not aware of any specific evidence, such as studies or literature, showing that holding patients increases an ED's legal risks. "But you cannot ignore the fact that being left in a hallway is not going to create an impression of well-organized health care," says Adelman. "That alone may make patients much more willing to believe they were not properly cared for."
Adelman says that he firmly believes "that an unanticipated bad outcome coupled with dissatisfaction with some aspect of the care provided are the primary ingredients of a malpractice claim." He recommends the following:
- Be sure that sicker patients whose condition could deteriorate more rapidly are kept in locations where they can be more readily and regularly observed.
- Be clear regarding who is responsible for the boarded patient, both with regard to the nursing staff and physicians.
- Make regular contact with the patients and their families, and explain to them why the patient is being boarded.
- Make an effort to provide privacy.
- Have a good explanation of why boarding was necessary readily available.
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