Report puts spotlight on inpatient holds: The No. 1 reason for ED overcrowding

You’ll need creative strategies to tackle this dangerous problem

Holding admitted patients waiting for an available bed not only hinders your ability to provide quality care, frustrates staff, and hurts your bottom line, but it also is the single biggest factor resulting in overcrowded EDs, according to a just-released report from the Washington, DC-based General Accounting Office (GAO).

According to the report, Hospital Emergency Departments: Crowded Conditions Vary Among Hospitals and Communities, ED delays are closely linked to the inability to transfer patients to inpatient beds, which pulls staff and resources from ED patients.

The practice of holding admitted patients in the ED is dangerous because it hinders the ability to treat severely injured and sick patients, says George Molzen, MD, FACEP, current president of the Dallas-based American College of Emergency Physicians.

"It’s essential that patient care not be delayed, especially at a time when we have added responsibilities to be prepared to respond to disasters or acts of terrorism," he says. Demonstrate to administrators that the practice of holding inpatients is causing delays in EDs nationwide by showing them the GAO report, Molzen advises. "By doing this, there won’t be as much finger pointing at the specific manager," he says. "You can also use the report as ammunition to lobby for changes in holding of inpatients." (To access the complete report, see Resources at the end of this article. For strategies on holding of inpatients, see "Speed up orders for inpatients held in ED," ED Management, March 2003, p. 29, and "Use protocol to send inpatient holds upstairs," ED Management, April 2003, p. 43.)

According to the report, which included a survey of 2,000 EDs and six site visits, at least 75% of inpatients were boarded in the ED for two hours or more in the past year at one-third of the facilities.

Here are strategies that will help you successfully reduce delays caused by inpatient holds:

Create a "bed control" office.

Lack of an efficient bed control system is a problem at many EDs, says Robert W. Stein III, BSN, MSHA, RN, CEN, CHE, president of LeNurse, a St. Cloud, FL-based consulting firm that provides medical-legal services to health care providers. The process of obtaining a bed assignment may depend upon the day of the week, the time of day, and even the nurse who happens be working a particular shift, he explains.

Inpatient nurses may fail to update computers when a patient is discharged, adds Stein. "This leaves the appearance that the room is still occupied," he says.

At Methodist Children’s Hospital in San Antonio, a bed control nurse and nurse administrator work to facilitate placement of admitted ED patients, says Janice Elliott, RN, the facility’s senior clinical administrator. "We identify areas that are in crisis or moving toward crisis, and try to intervene in the most appropriate way," says Elliott. "We consider ourselves to be a little like air-traffic controllers." 

The bed control office monitors bed status and sends pages out to charge nurses and nurse managers to inform them if units are "clear," "on alert," or "at capacity," she explains. "This lets everyone know if they need to look at how many potential dismissals they have and how many patients could be downgraded to the next level of care," says Elliott.

When the ED is in the alert or at capacity stage, steps are taken immediately to get inpatients moved upstairs, says Elliott. "We go and assess which patients can be moved or go home, to free up more beds," she says. For example, physicians are contacted to determine if patients can be discharged or downgraded from the pediatric intensive care unit to the regular floor so that patients can be moved out of the ED, she explains. "It is imperative that the person doing bed control have a working knowledge of EDs and how crucial it is for them to move patients," she says. "Without that, you can end up with congestion in the ED that is crippling to staff and patient movement."

Use inpatient nurses to care for admitted patients being held.

Unlike ED nurses, floor nurses already are familiar with the standards of inpatient care, notes Stein. "They can provide the necessary care without being distracted by an acute myocardial infarction or motor vehicle crash arriving via ambulance," he says.

Since the revenue for these patients already is going to the inpatient units, the cost of inpatient nurses working in the ED can be charged back to the inpatient unit, explains Stein. "This adds a financial incentive to motivate the inpatient nurse managers to help solve the ED problem,’" he says. In addition, inpatient nurses may be more willing to facilitate patient transfers after seeing the conditions in the ED for themselves, he adds.

At Methodist Children’s, a staff person designated as a "SWAT" nurse has a dramatic impact on inpatient holds in the ED, says Elliott. This floating nurse assists with incoming admissions and discharges, transports patients to radiology, and cares for inpatients in the ED, she explains. To free ED nurses, inpatients held in the ED overnight often are moved into an observation area and assigned to the SWAT nurse and a technician who can care for up to four of these patients until the morning when beds become available, says Elliott. The SWAT nurses are accustomed to taking care of inpatients, but they also are oriented to the ED, says Elliott. "They can transfer the patients over to computer charting, give medications, and do everything just as they would on the floor," she says.

This system results in better continuity of care, because ED nurses unaccustomed to caring for inpatients may miss routine orders such as repeat antibiotics or medications, says Elliott.

Add a second charge nurse in the ED.

Keeping track of patient flow in a hectic ED is a challenge for even the most seasoned charge nurse, Stein says. "Add tracking inpatients on top of that, and things will get missed," he says. On occasion, inpatients being held in EDs have gotten "lost" and remained hours to days after an inpatient bed was available, he notes. To address this problem, consider adding a second charge nurse to each shift, Stein recommends. The "co-charges" can work as a team and communicate with a computerized patient tracking board and walkie-talkie radio contact. One nurse can focus on patients in the ED waiting room and treatment rooms, and the other can track the flow of admissions, he advises.

Have an admissions nurse handle inpatient documentation.

At Osceola Regional Medical Center in Kissimmee, FL, inpatient nurses were resistant to accept admitted patients from the ED because of the need for an extensive nursing admission history, nursing assessment, and care plan, says Stein, the facility’s former patient service leader for emergency services. "The assessment and computer time to document could take up to an hour for each admission," he says.

The facility’s policies required the receiving nurse to complete and document these admission notes before leaving at the end of the shift, he explains. "This may be difficult to impossible to achieve under the excessively high nurse-to-patient ratios created by the nursing shortage," Stein says. ED nurses are not trained to document these inpatient assessments and lack time to complete them, he explains. To solve the problem, a new "admissions nurse" position was created to complete and document assessments while the patient is in the ED waiting for an inpatient bed to become available, Stein explains. "By having the admissions nurse complete the required documentation before the patient was transferred, the inpatient nurses were more amenable to immediately filling a bed as soon as it became available," Stein says.


Janice Elliott, RN, CEN, CFRN, Senior Clinical Administrator, Methodist Children’s Hospital, 7700 Floyd Curl Drive, San Antonio, TX 78229. Telephone: (210) 575-7104. Fax: (210) 575-7156. E-mail:

Robert W. Stein III, BSN, MSHA, RN, CEN, CHE, LeNurse, 4069 13th St., No. 112, St. Cloud, FL 34769-6701. Telephone: (407) 891-1911 Fax: (407) 891-8639. E-mail: Web:

• The complete March 14, 2003, report Hospital Emergency Departments: Crowded Conditions Vary Among Hospitals and Communities is available free at the United States General Accounting Office web site ( Click on "GAO Reports," "Find GAO Reports," and type in "GAO 03-460" without the quotation marks. Also, single printed copies of the report are available at no charge. To order, contact U.S. General Accounting Office, 441 G St. N.W., Room LM, Washington, DC 20548. Telephone: (202) 512-6000. Fax: (202) 512-6061.

• The Joint Commission on Accreditation of Healthcare Organizations is seeking comments on a proposed leadership standard to address ED overcrowding. The proposed standard calls on hospital leaders to implement plans to identify and address situations that result in ED crowding, such as performance improvement activities, coordination with community resources, and tracking the capacity of units that receive ED patients. If approved, the standard would be implemented in January 2004. The deadline for comments is June 2. The draft standard and an on-line evaluation form can be accessed on the Joint Commission web site ( Click on "Accredited Organizations," "Hospitals," "Standards," "Field Reviews," "Emergency Department Over-crowding." For more information, contact Joyce B. Marshall, Division of Research. Telephone: (630) 792-5934. E-mail: