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Not Just an ED Problem: How to Solve the Boarding Problem Caused by Staff Shortages

By Stacey Kusterbeck

Staffing shortages in other hospital units are exacerbating the long-standing problem of ED boarding of admitted patients, according to Stephen Colucciello, MD, FACEP, clinical professor of emergency medicine at Atrium-Wake Forest Baptist in Charlotte, NC. Colucciello recently spoke with ED Management (EDM) about what can be done to solve this complex problem. (Editor’s Note: This interview has been lightly edited for length and clarity.)

EDM: What can hospitals do to mitigate boarding?

Colucciello: Boarding is not an ED problem, although we are the ones who suffer from it, and our patients suffer from it. Boarding is a hospital flow problem — it’s a hospital issue.

While the ED can do some things to mitigate it, you need full buy-in from the administration to decrease boarding. There are some obvious regulatory and legal concerns. Boarding has huge effects on ED metrics, safety, and medical/legal concerns. There is very robust literature on the impact of boarding on every aspect of ED operations and ED care. Overall hospital length of stay, left without being seen rates, the number of patients leaving without completing treatment, patient complaints, and mortality — especially boarding for more than four to six hours for ICU patients — all directly correlate with boarding. Time-to-antibiotics and time-to-treatment of cardiac problems increases.

The answer is not building more beds. It would take five years to do that, even if you were to get approval today.

There are many ways to decrease boarding. Some hospitals are looking at surgical schedule smoothing. By operating seven days a week, you don’t have most of the surgeries on Monday and zero on Friday and the weekends. You can also increase hallway boarding. If you have 20 inpatient units in a big hospital, and you put two people on each inpatient hallway, now you have 40 additional beds. And those can be used for patients who are waiting in the ED for the room to be ready, or for patients who are waiting to be discharged. The use of a discharge lounge is also useful. Preparation for discharge, starting on admission, should be routine. A well-functioning hospital should have at least 60% of the discharges by noon.

Another novel approach is express admit units. As soon as the person is admitted, they move out of the ED. That unit can be staffed eight, 12, or 24 hours a day, depending on the hospital’s size, flow, and needs. But those nurses take care of all the initial orders and all the initial intake, and start the discharge planning process. It’s geared toward getting patients out of the ED and starting their care. As soon as a bed opens up, the patients go there. The burden of the inpatient nurses on the unit is lessened. An express admitting unit can be extremely important in terms of mitigating boarding.

But all of these things can be instituted, and you still have the problem of ED boarding.

EDM: What can emergency providers do directly about the problem, since hospitalwide staffing shortages are out of their control?

Colucciello: Most of these changes are out of the hands of the ED providers. One thing that’s in our control is who we discharge. This is one of the places where we need to be strategic.

ED providers can decrease the number of admissions safely. EDs can do this by increasing the use of long-acting antibiotics for soft and skin tissue infections. EDs can also send home most atrial fibrillation patients, as long as they meet certain parameters. You put them on a beta-blocker or a calcium channel blocker, a direct-acting oral anticoagulant, and you discharge them for follow-up cardioversion as an outpatient.

For chest pain patients, if you do an ECG on arrival and in an hour and there are no ECG changes, there are no high-sensitive troponin bumps, the patient is hemodynamically stable, and there is no history of coronary artery disease, [discharge them]. It is important to obtain a second high-sensitivity troponin at one hour along with the second ECG. But you may be able to safely discharge the patient with a HEART score of a 4 or 5, and some people even suggest patients with a score of 6 can be discharged safely.

We’ve learned more about telemedicine in two years than we have in decades. If you have community medics or community nurses, you can send patients from the ED to hospital at home directly for daily or twice-daily blood pressure and vital sign checks. You can then send home 20% more of your ED patients than you previously admitted. In addition, for patients who do get admitted, if those patients normally had a length of stay of six days, and you start sending home stable patients on day 2 to be treated and monitored at home, then length of stay has gone from six to two days.

Now that direct oral anticoagulants are around, it is so easy to send a stable pulmonary embolism patient with low severity score home. You have to have a protocol on who’s safe to go home and be seen as an outpatient. You follow the protocols, use the scoring system, and look at the risk of bleeding.

You also want to see if they have a home and a phone vs. living on the street. You need to consider social determinants as well. Can they get their medicine, or can you give them their medicine? For hospitals that dispense medicines, the payoff is huge. Paying for a direct oral anticoagulant is a fraction of the cost of a six-day uncompensated hospitalization. We’re talking about $100,000 compared to a couple hundred dollars.

Obviously, you don’t send unstable patients home. But I’m wagering that 50% of patients admitted from the ED for atrial fibrillation didn’t need to be admitted. Changing our admitting practices to safely discharge patients is the one thing that is clearly in our control. We might not be able to smooth the surgical schedule or force the inpatient hallway beds, but we can discharge more patients safely.

EDs can appoint someone in the department to be policy coordinator. Each month, you can look at one policy — for pulmonary embolism, atrial fibrillation, pneumonia, or skin and soft tissue infections. If you’re going to embark on decreased admissions, it needs to be evidence-based.

There’s more to this than just the HEART score. Clinical judgment has to [factor] in, too. But if we actually look at the electronic medical record, and we start doing more benchmarking of what our practice is, we’ll realize that the average EP can safely send home 20% more patients. On top of that, if the hospital would start investing in telemedicine so patients don’t have to come back to the ED the next day, that could really make all the difference.

EDM: What are the biggest obstacles to alleviate boarding?

Colucciello: The forward-thinking and disruptive approach can be painful. The surgeons are not going to like the 24/7 scheduling. It may not be 24/7; it may be 16/7, and all days of the week you have the same number of operations.

Hospitals have to spend money on the express admit units and nurses to staff those units. But if hospitals don’t do those things, there are costs involved — patient complaints, medication errors, patients choosing to go to another hospital for emergencies. The cost is far more, in terms of the bigger picture, than it will cost to staff an express admit unit. There are lots of [tactics]. It takes thought, planning, and some amount of money. But this boarding issue definitely needs to be met head-on and addressed.