Waiting for the waiting to end

ED boarding is dangerous, and fixable

Ask passersby in a hospital hallway what they think the biggest problem is in the emergency department, and one of the most common answers will likely be something about the influx of uninsured patients who use the ED as their primary care physician. Ask an ED physician or nurse for an opinion, and the answer is much more likely to be boarding.

It is an intractable problem in many hospitals, and one that at first glance someone might think was related to a lack of patient beds. But in the United States, hospital occupancy is around 70%, and while some hospitals may be fuller, there are very few facilities that have no room at the inn at all. So what's the problem and why should you care?

According to numerous studies, boarding patients can lead to inferior care for the boarded patients, and may also affect the care provided to incoming emergency cases. Many of these studies were mentioned in an August Health Affairs article that looked at the dangers of boarding, the reasons behind it, and potential solutions1.

One of the study authors, Elaine Rabin, MD, an assistant professor of emergency medicine at Mt. Sinai School of Medicine in New York City, says boarding seems like a big secret they aren't trying to keep in the emergency department. "What was obvious to us in this study is surprising to others," she says. The hospital community at large may know that EDs are crowded, but they don't associate that crowding with boarded patients who are waiting for a room elsewhere in the hospital.

The consensus paper on which Rabin worked noted that boarding increases length of stay and can adversely affect outcomes for patients because they may not get the attention or level of care they need while waiting in a busy ED for a bed on a quiet floor with more access to care and nursing; they may not get medicines in a timely manner; or it prevents other patients from getting access to care because the ED is too crowded — sometimes so crowded that it is closed and ambulances are put on diversion, forced to find another facility that may be precious minutes and miles away.

Among the reasons for boarding, the authors noted, are inefficiencies such as an inability to get some tests or schedule surgeries on a 24-7 basis. If a bed is reserved for an elective patient, or an emergent patient can't get an MRI as quickly on the weekend, then the whole system backs up. Some hospitals don't discharge patients on weekends, but that may be a really busy time for the ED, and since boarding mostly likely occurs when hospitals are at their busiest, but not full — usually when they are around 80-85% of capacity — the potential for boarding in those facilities is probably greater.

One interesting finding, Rabin says, is that some hospitals actually make money when their hospital is on diversion, making boarding a financial win. Emergency patients are often a loss leader for a hospital. Elective patients are worth more money. By closing the ED because it is full of boarded patients, a hospital can limit that negative mix to its income.

"It is not a completely unintended problem in some places," she says. But there are other hospitals that have shown that by solving boarding problems, they can make more money.

There are fixes that can address the problem in a dramatic way. The authors found that smoothing surgical schedules so that they are more equally spread throughout the week helps, as does moving boarded patients to inpatient hallways, which are quieter and have more available nurses. Creating a bed "czar" who will monitor and manage bed availability, having a discharge lounge for patients to wait in before leaving (rather than in their room, occupying a bed), and streamlining the admissions process all have worked. But the problem is that few organizations are using these strategies to address the problem of boarding.

The Health Affairs article noted that in the United Kingdom, press stories about long waits in emergency rooms led to patient uproar and eventually rules that require patients to be seen within a specified time. While there hasn't been patient outcry in this country, Rabin thinks that if something isn't done soon, we are moving to a time when there will have to be some legislative fix to this problem.

"I don't know if we need new legislation, but there will have to be an external force to do this," she says. "All these answers are out there and they haven't been picked up. Hospitals always have a list of things they have to do, that are mandated. Maybe getting to the things they should do but aren't mandated is too hard."

One of the facilities that addressed the problem using surgical schedule smoothing was Boston Medical Center, which accepted a $250,000 grant from Robert Wood Johnson Foundation to implement the program. It took a lot of "good diplomacy" to get the program up and running, says Rabin, but it worked and is part of the lore of ED boarding success stories.

One of the people who followed that project closely is Jeremiah Schuur, MD, MHS, FACEP, director of quality, patient safety and performance, department of emergency medicine at Brigham and Women's Hospital in Boston. He has written about the problems that come with boarding2. "The most dangerous place to be in a hospital is the ED," he says. "When a patient has been admitted, they need more care, and that is best provided by another unit in the hospital. They aren't getting that care because they aren't on the right ward, they aren't where the physicians are or the nurses are who can best meet their needs." Emergency physicians are trained to provide a certain kind of care — diagnosis and rapid treatment. And if a quarter of the ED is taken up with patients who need to be somewhere else, who isn't getting in to see an emergency room physician? he asks.

The American College of Emergency Physicians (ACEP) has long had tools and strategies available to address the problem. Schuur has his favorites, including Boston Medical Center's surgical schedule smoothing, and SUNY Stoneybrook's tactic of putting boarded patients in the hallways of inpatient units. "At some point, they are going to the floor anyway," he says. "It is safer for them there, and quieter. Once they get on the floor, it is amazing how fast things can happen to get them a bed."

Cutting out admission steps, combining them, or waiting to do some of those things until a patient has a bed also works for some organizations. One thing he's not a fan of is mandating a maximum wait time for admission. "It can lead to perverse decisions as you near the time limit for admitting a patient. Some patients may not be admitted who ought to be, for instance, or you might admit others who with a little more time, you would determine could just go home."

What might work better is to make the time boarded and number boarded a reportable statistic that people in the community can see. "If you say this is a bad thing and it is publicized, it might force the issue," Schuur says.

At Brigham and Women's Hospital, there is a surgical pod that can be activated and opened within the emergency department as needed, which can help take up any slack that comes from no room in other operating theaters. And they also have streamlined processes to get inpatient teams to take care of the patients as early as possible, whether the patients are still in the ED or not.

The reason that his ED has been able to address the problem is that the leadership responds to and respects the leadership in that department. It is something Schuur says isn't true everywhere. For organizations that might have administrators who are blind to the program, he recommends having them come down to talk to patients and family members of patients who are boarding or who have boarded. That might make them see the issue differently.

Making the most of other changes

At St. Clair Hospital in Pittsburgh, an emergency department expansion project provided a time and a chance to help address boarding, says Tania Lyon, PhD, director of organizational performance improvement at the hospital. "We overhauled our staffing model, standardized our intake process, launched an inpatient throughput initiative that included a change in our daily bed meetings, and added an electronic status board to the department to track patient status in real time," she says. Wait times plunged, even before the new wing of the ED was opened, and patient satisfaction went from 14% nationally to 99% in about 18 months, door-to-physician time is nearly half of its previous level at 41 minutes; left-without-being-seen numbers dropped from 130 per month to 15 per month, and door-to-room times went from 54 minutes to 18 in the ED itself. Boarding? It is been virtually eliminated.

The changes in the ED led the hospital to win a gold Fine Award in 2009, and another in 2011 for sustaining the improvement, even while the number of people being seen has increased by 20% and not a single inpatient bed was added.

Boarding rates aren't something that many hospitals — including St. Clair's — measure. But before the improvements it was an issue, "and now it isn't. We doubled the size of the ED, which means there is a lot more space. But if we hadn't fixed this problem, then we would have just shifted the waiting area."

Part of the success was that throughput for all patients was a project — not just ED patients, but every patient. The goal was to figure out how to get them out of the hospital as fast as possible while giving them all the care they need and the highest quality of care. "Getting someone out of the hospital frees up a bed and gets someone out of the ED," Lyon says. "We looked at the discharge process first, at the end. We looked at the unnecessary delays in getting patients out."

One solution was to overhaul the culture of case managers, changing their focus to working with the physicians to establish parameters for discharge. What has to happen to get this patient home? What tests, what environmental assurances, what improvements in their status had to occur for the physician to send one out the door? Is what they need something they have to get in the hospital, or can they get it at home? Those goals are documented in the patient chart, along with the diagnosis and treatment plan.

Another change, which was simple and cheap, was to change the focus of the morning bed meeting. Despite being called bed meetings, they had devolved to a discussion of what staffing was needed, what the patient census looked like, where there was a shortage of nurses, and who could fill that gap. Now, the bed manager focuses on how and where to move patients around at twice-daily meetings — in the morning and late afternoon. They last five minutes, and attendees talk about who will be discharged and which beds will open up that day. "The focus is on pulling people out, not pushing them in. We made this a hospital problem, not an ED problem."

People thought that boarding and crowding were ED problems, she continues. But they are not. They are an issue of throughput. The bed meetings affected that culture by changing the focus and attitudes of nursing leadership on down the line. "Now we have nurses and doctors talking very differently with each other," Lyon says. It took two years to make all the changes and develop a smooth process that focuses on parameters for discharge. After piloting on a single unit, that program is now spreading facilitywide.

Special patients, special needs

At UC San Francisco, boarding of pediatric patients was an issue that Arpi Bekmezian, MD, an assistant professor, looked at in a study that found that boarding patients costs more, leads to longer length of stay, and has higher mortality and morbidity3. One thing she found was that even the less severely ill patients are likely to suffer when they board. "They are more likely to be ignored because they aren't seen as critically ill," she says.

Bekmezian's work on the topic in the past has shown that certain groups of people are more likely than others to be at risk for boarding. Hispanic patients may wait longer for a bed because there isn't a ready interpreter. Patients who come in the early morning and the winter are more likely to board, possibly due to inadequate staffing in the wee hours or inability to plan for busy seasons — such as in a pediatric hospital during the winter flu season.

One fix that is specific to pediatrics is having a pediatric team available in a general ED that sees kids. "Not all staff is comfortable treating kids," she says. "Having someone conversant in dealing with children who need complex care can help." They have a pediatric resident, attending, and nurse who deal with boarding kids to make sure that they aren't lacking appropriate care while they wait for a bed. It might translate to other special populations — geriatric, for instance — if you see a lot of a particular kind of patient in the ED and you have a boarding problem. It might work in general to have a few people who are dedicated just to boarding patients while other fixes are being worked out. "It is an expensive solution, but it provides the attention the boarding population needs," she says.

Bekmezian has worked in an ED where there were boarders, and on a ward where there was a patient of hers waiting for a bed. Either way, boarding is distracting. If she's a physician in the ED, she can't pay as much attention to the boarded patient as that patient needs, or if she does, she is leaving some emergent patient without care. On the ward, she is too far from her patient to give proper care without leaving her other patients in the lurch.

Another special population whose boarding needs should be addressed is psychiatric patients, says Muhamad Aly Rifai, MD, CPE, the chairman of the department of psychiatry in the Blue Mountain Health System in Pennsylvania. Also a professor of clinical psychiatry and medicine at the Commonwealth Medical College, Rifai says psychiatric patients were being boarded for five times longer than other ED patients — as long as 15 hours. Those patients experienced more agitation, were more likely to need restraints and isolation, and were more likely to be involved in staff member injuries.

"On the month prior to initiating our project for reducing the length of stay, there were five nurses who were out on disability related to injuries they sustained while caring for patients with psychiatric complaints being boarded," Rifai says.

The problem was clear to everyone. Initially, leadership responded by arming security personnel with stun guns, which resulted in five patients being stunned in a three-month period. The Joint Commission and Department of Health investigated as a result. Stun guns were not the answer, he says, so they created a joint task force from the department of psychiatry and the department of emergency medicine to see what might work to reduce the boarding problem.

In 2007, the group evaluated patient flow and started tracking length of stay and boarding. They created an alert system to improve communication regarding psychiatric patient volumes. The collaborative group met regularly and implemented changes including scheduling discharges effectively, improving flow, combining electronic medical records and multi-tasking. Physicians and staff were educated and supported to improve and standardize the evidence-based assessments dealing with acute patients who had suicidal or homicidal ideation. Algorithmic evidence-based management strategies of acutely agitated patient were implemented.

While psychiatric patient volumes actually increased by nearly a quarter between 2007 and 2010, the length of stay decreased by a third, to 10 hours. Patient boarding decreased by 40%, and there was an 85% decrease in staff injuries and 50% reduction in seclusion and restraint use among boarded patients, Rifai notes. The project was presented to the American College of Physician Executives annual meeting. A poster presentation can be viewed at http://net.acpe.org/Current_Materials/Summit/Share%20_Your_Story/Posters/Rifai.pdf.

The key lesson from Rifai's perspective is teamwork. The problem doesn't belong just to the emergency department, but to the whole facility or system.

The point Rabin would like to make is that there are solutions that work out there, and they should be used more frequently. If they aren't, then calls for mandatory interventions will only increase.

"Hard time frames may become necessary in the future," says Schuur. "But we should start by actively pushing for public reporting of measures related to boarding first. It is an invisible problem. Making it visible will be a major incentive to address it. Then, if that doesn't work, maybe we move on to time limits."

For more information on this topic, contact:

  • Muhamad Aly Rifai, MD, CPE, Chairman, Department of Psychiatry, Blue Mountain Health System and Clinical Professor Psychiatry and Medicine, The Commonwealth Medical College, Leighton, PA. Email: DrRifai@alyrifai.com.
  • Arpi Bekmezian, MD, Assistant Professor, UC San Francisco School of Medicine. Telephone: (415) 476-6366. Email: bekmeziana@peds.ucsf.edu.
  • Tania Lyon, Ph.D., Director, Organizational Performance Improvement, St. Clair Hospital, Pittsburgh, PA. Telephone: (412) 942-1149. Email: tania.lyon@stclair.org.
  • Jeremiah Schuur, MD, MHS, FACEP, Director of Quality, Patient Safety, Performance Improvement, Dept. of Emergency Medicine, Brigham and Women's Hospital, Boston, MA. Telephone: (617) 732-5640. Email: jschuur@partners.org.
  • Elaine Rabin, MD, FACEP, Assistant Professor Emergency Medicine, Mt. Sinai School of Medicine, New York, NY. Telephone: (646) 522-3604. Email: elaine.rabin@mssm.edu.

References

  1. Rabin E, Kocher K, McClelland M et al. Solutions To Emergency Department 'Boarding' And Crowding Are Underused And May Need To Be Legislated Health Affairs, 31, no.8 (2012):1757-1766.
  2. Liu SW, Chang Y, Camargo CA et al. A Mixed-Methods Study of the Quality of Care Provided to Patients Boarding in the Emergency Department: Comparing Emergency Department and Inpatient Responsibility Models. Med Care Res Rev. 2012 Aug 23.
  3. Bekmezian A, Chung PJ .Boarding admitted children in the emergency department impacts inpatient outcomes. Pediatr Emerg Care. 2012 Mar;28(3):236-42.