ED boarding creates patient safety issues, increases risk of mortality

Solution should be a hospitalwide initiative

Keeping admitted patients on stretchers in hallways because there are no inpatient beds available is an increasing problem as emergency departments experience an increase in patients and hospitals downsize their bed capacity.

The emergency department is a place for patients to be diagnosed, stabilized and then discharged home or admitted to the appropriate level of care, but it’s not a place for patients to receive care, points out Tonya Kirby, BSN, MHA, MBA, senior director quality and safety collaborative for the Premier healthcare alliance.

“It’s important to get patients in the right bed sooner rather than later. Patients who are sick enough to be in the hospital need to be in the right bed and receive appropriate care, and the emergency department is not the place for that,” she says. The longer the patients stay in the emergency department, the more the risk of mortality goes up, Kirby says.

Emergency department boarding, otherwise known as excessive waits for inpatient beds, results in negative outcomes, ranging from an increased risk of mortality to lower patient satisfaction scores, adds Patricia Hines, PhD, RN, vice president of The Camden Group, a national healthcare consulting firm.

The biggest issue with emergency department boarding is patient safety, Hines says. When patients are in a hallway or sitting on a cart and waiting to be admitted, there is an increased risk of an adverse event, she says. In addition, emergency department boarding often means delays in patients receiving the treatment they need, she says.

“It’s definitely a quality issue. Emergency departments don’t have the equipment or the staff to take care of patients’ needs after they are stabilized. The staff is trained to triage patient needs, provide emergent care, ensure that patients are stabilized and moved to the floor or discharged. Leaving patients in the hallway with somebody checking on them is not the same thing as having a floor nurse caring for the patient,” adds Linda Sallee, MS, RN, CMAC, ACM, IQCI, director for Huron Healthcare with headquarters in Chicago.

Hines quotes a data brief from the National Center for Health Statistics that determined that in 2009, 78% of emergency department patients were held in emergency departments that reported boarding patients in hallways and other spaces while waiting for an inpatient bed to become available. “When beds are full and the emergency departments go on diversion, it’s a challenge, particularly when the emergency department is the only one in the area,” she adds.

The Joint Commission is focusing on patient throughput and has expectations that hospitals not only collect data but create solutions, Hines says. “One of their standards requires hospital leaders to set goals for improving throughput and involve the entire healthcare team in creating solutions. That’s an area that Joint Commission surveyors are looking at,” she says.

Hold-ups in the emergency department also can affect a hospital’s scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), Hines points out. “Now that the Centers for Medicare & Medicaid Services has instituted value-based purchasing and the HCAHPS scores are a factor in reimbursement, this clearly should be a point of concern,” she says.

Emergency department boarding affects more than the emergency department. It affects the entire organization, Kirby says.

“To avoid emergency department boarding, the inpatient staff has to get patients moved out in a timely manner when they no longer meet inpatient criteria. Hospitals have to start at the back door and work their way backwards to fix what is going on in the hospital, and that will help to fix emergency department boarding,” Kirby says.

When patients aren’t discharged in a timely manner, it creates a vicious cycle, Sallee says. Patients can’t move from the intensive care unit or telemetry unit because a medical-surgical bed isn’t available, and new patients who need to be in intensive care can’t be moved out of the emergency department.

“In order to improve patient throughput, hospitals must have good admission and discharge criteria for each unit,” she says.

Improving throughput should be a continuous process improvement plan, Hines says. “The key is to have a multidisciplinary team examine the reasons for the problems with throughput and collaborate on solutions,” she says. Include representatives from the emergency department, nursing services, ancillary professionals, and physicians.

Look at bed utilization, length of stay, and when and how quickly patients are discharged, Kirby advises. Determine what drives the discharge process, such as the surgery schedule or the admitting physicians’ clinical schedule, and take steps to improve.

Appropriate utilization of beds, particularly in the intensive care unit, the telemetry unit, or medical-surgical units, is usually the roadblock to optimal patient throughput, Kirby says.

“Over-utilization of telemetry is one of the biggest problems, and hospitals have started using order sets based around telemetry,” Kirby says. For instance, patients may be on telemetry monitoring for three days without an arrhythmia. In these cases, the nursing staff should be able to discontinue telemetry and move patients to a lower level of care, Kirby says.

“If the intensive care unit and other units don’t have discharge criteria, patients are not moved out in a timely manner and they get backed up, Sallee adds.

Analyze the time that discharge orders are written, the time at which patients leave, and what happens in between, suggests Brenda Keeling, RN, CPHQ, CPUR, president of Patient Response, Inc., a Durant, OK-based healthcare consulting firm.

Implement a team to determine what is holding up the discharges and initiate steps to remove or minimize delays.

For instance, identify delays in the time it takes the laboratory to turn over reports, which can delay the physician in making a timely decision to discharge the patient. Tabulate the delay between the time the discharge order is written and the time the patient leaves the hospital. Determine how long it takes environmental services to clean vacant rooms and get them ready for the next patients.

“It’s important for the entire team to work together and include the family in the plan of care for the patient,” she says.

Make sure there is constant communication between the emergency department and the nursing staff on the patient units, Keeling suggests. Some hospitals post their electronic bed board information in the emergency department and on the nursing units so that supervisors, charge nurses, case managers, social workers, other clinicians, and environmental workers have constant access to bed status at all times. The best process is not to wait until the bed availability is reaching a critical low but to implement a team approach for discharge planning that frees beds when patients are stable enough to be discharged, she says.

“When the supply of empty beds is getting low, it is crucial for physicians to work closely with case managers, social workers, and charge nurses to triage patients meeting discharge stability on individual units. The staff should be held accountable for facilitating those discharges in a timely manner,” she says.

As soon as the nursing unit is notified that a patient has been admitted, the nurse should initiate the transfer, Sallee says. Sometimes nurses say a room is not ready for patients because they don’t want another patient at that time, Sallee says. “They don’t think about the consequences for the patient and for the hospital. Nurses need to develop a different frame of mind and focus on doing what’s best for the patient rather than thinking a newly admitted patient is just someone else to care for,” Sallee says.

Develop a system to notify housekeeping as soon as patients leave their rooms so empty beds will be available. Look at the hours your housekeeping staff are on duty. If a bed becomes empty in the evening and there’s not a housekeeping person to clean the room, it can contribute to the emergency department backlog.