Standard of Care May Be Breached with Boarding

Attorneys will claim poor care given

If a bad outcome occurs with a boarded patient, what standard of care will the ED be held to? "That's a big debate," says Matthew Rice, MD, JD, FACEP, senior vice president and chief medical officer at Northwest Emergency Physicians of TEAMHealth in Federal Way, WA. "What does not look good is if a patient is sitting in the hall."

The idea of being in a hall instead of a room may be viewed negatively by a jury. "Whether the care is better or the same is what juries will sort out in a trial, relative to their decision," says Rice. "But if the patient is in the hallway as opposed to a room with a private bed and more staff to watch them carefully, and there is a bad outcome, the theory is that the care was not as good as if the patient moved to an appropriate floor that took care of their medical or surgical problem."

The issue is whether the bad outcome occurred because the patient should have been somewhere else. "Was the standard of care breached because they were in the ED vs. a different location?" asks Rice. "Plaintiffs typically argue that care should have been, or would have been, better or different."

A patient with a neurosurgical emergency who is boarded in the ED because there are not enough beds in the intensive care unit (ICU) is monitored, but not to the same standard of care that they would be if they were in a neurological ICU.

"So the argument is, if you had moved them there three hours earlier, the patient would have had better, closer monitoring than you provided in the ED," says Rice. "Then you get into the argument, 'Should the nurse have known to do XYZ? Should the ED physician have been more involved in the care?'"

ED nurses may struggle to see new patients while taking care of the boarded patients. "Is there negligence because there is not appropriate nurse staffing to attend to the patient that had a bad outcome?" asks Rice.

Error-prone Situation

Boarding produces error-prone circumstances because of the inability to provide all services necessary for the patient, according to Rice. "Mistakes can occur with tests not being done or reviewed. The wrong medicines can potentially be given, or given at the wrong time," he adds.

Of course, the fact that a patient is boarded doesn't necessarily mean he or she is not getting good care. "But if they have a bad outcome, the question will be raised as to why they were there so long, and whether they could have gotten better care elsewhere," says Rice. "In raising the question, plaintiff's attorneys will try to stir the pot of what wasn't done right, and ask the question, 'Should they have been somewhere else?'"

Although crowding is a hospital-wide problem and is not the individual ED physician's fault, he or she typically still would be named in a lawsuit alleging poor care due to crowding. "Most litigation spreads a wide net. They try to include everybody and exclude them later," says Rice. "Part of that is the strategy that the more people you name, the more access you have to the deep pockets of more insurers, rather than just one insurer."

While a boarded patient can still receive good care in the ED, hospitals don't always have the ability to provide the same resources as ICUs. "Monitoring devices are limited in numbers, and care providers are limited in numbers," says Rice. "Often, hospitals cannot mobilize other resources to come to the ED to staff the patient relative to the usual accepted ratios of how many nurses you should have per patient."

If you have a ratio of one nurse to every four ED patients, and that same nurse has three patients in the hallway in addition to the four rooms that are filled, the argument is that the nurse shouldn't have had those three extra patients, and this caused the bad outcome.

Different Setting

"Putting a new ED patient in a hallway may lead to corner-cutting regarding the physical examination, as patients do not get undressed, and EKG testing, especially in women, due to lack of privacy," says Tom Scaletta, MD, FAAEM, chair of the ED at Edward Hospital in Naperville, IL.

Admission orders may not always be adhered to. "It is difficult for ED nurses to implement these. They are often involved, whereas ED orders are generally quite different," says Debra J. Gradick, MD, FACEP, medical director of the ED at Avista Adventist Hospital in Louisville, CO, and vice president of operations at Serio Physician Management in Littleton, CO. "We are addressing the acute problem at hand, and not ordering a plethora of tests which are extremely difficult to execute."

Boarded patients may not be assessed as often as they should be, simply because of inadequate staffing issues. One solution is to bring in an ICU nurse to care for the more critical inpatients being held. "Chances are if the ED is crowded, the ICU is as well. You can't always pluck out an ICU nurse or grab one to come in from home. That is not realistic," says Gradick.

Scaletta says that it is unfortunate that many hospitals still resist any form of inpatient boarding. "Many prefer having six non-ICU boarders in the ED rather than one boarder on each of six non-ICU units," he says. "Often this is a function of inadequate inpatient staffing, which may be an intentional means to shrink expenses."


For more information, contact:

• S. Allan Adelman, JD, Adelman, Sheff & Smith, LLC, Annapolis, MD. Phone: (410) 224-3000. Fax: (410) 224-0098. E-mail:

• Debra J. Gradick, MD, FACEP, Medical Director, Emergency Department, Avista Adventist Hospital, Louisville, CO. Phone: (303) 673-1003. E-mail:

• Tom Scaletta, MD, FAAEM, Chair, Emergency Department, Edward Hospital, Naperville, IL. Phone: (630) 527-5025. E-mail:

• Robert B. Takla, MD, FACEP, Chief, Emergency Center, St. John Hospital and Medical Center, Detroit, MI. Phone: (313) 343-7071. E-mail: