ED to Wards: Beating the Boarding Problem

Boarding has been a growing problem over the last decade and may worsen – at least in the short term – with the fuller implementation of the Affordable Care Act, according to experts who are calling for hospitals to implement proven remedies.

Hospital efficiency has suffered as institutions seek to cut costs while coping with a rising influx of uninsured and Medicaid patients. That financial pressure will not improve under health care reform, at least not initially, as millions more Medicaid patients are likely to seek care in the ED when they cannot access primary care, Dr. Jody Crane, emergency department faculty for the Institute for Healthcare Improvement, Cambridge, Mass., said in an interview.

Medicaid pay is already low, and an estimated 8 million more Medicaid patients will visit EDs annually after reform. In addition, as Medicare dials back its reimbursement to hospitals and physicians to help fund the Affordable Care Act, Va. That will put a squeeze on already tight hospital margins, he said.

"Every hospital is going to have to do the same or more with less," said Dr. Crane. Boarding – holding patients in the ED while they wait for admission to inpatient services – can be costly, reduces patient satisfaction, and has been shown to ultimately increase length of stay and mortality.

"Boarding in some hospitals is a capacity issue, but in others it’s also a management issue," Dr. Crane pointed out. Technical issues, including matching resources to the demand coming through the door, are also factors, he said.

"Ultimately, a coordinated effort is needed between the ED and the hospitalist to ensure quality transitions of care that maximize both health and financial outcomes," said Dr. Franklin A. Michota, director of academic affairs in the department of hospital medicine at the Cleveland Clinic. "Each hospital does need to analyze where their bottlenecks exist and whether a staffing solution is part of the answer. But the ED also needs to look at the accuracy and quality of their triage and their ability to adequately prepare the patient for the trip upstairs."

"For example," Dr. Michota continued, "sending a patient upstairs with sickle cell crisis and inadequate pain control just ties up the hospitalist unnecessarily and will delay the hospitalist in getting to the next new admission. Or failing to order a CT scan that would have sent a patient to the operating room and bypass the medical hospitalist altogether will again just delay getting to the next admission.

"Everything relies on everything else....the chain is only as strong as its weakest link."

Indeed, "the primary reason it’s a hard problem to fix is because it’s so multifactorial," said Dr. Jesse Pines, associate professor of emergency medicine and health policy at George Washington University in Washington, D.C.

What Works?

A recent study in Health Affairs showed that many hospitals still are not taking advantage of proven strategies to reduce boarding – among them, so-called smoothing of elective surgical schedules, active bed management by hospitalists, and the "full capacity protocol" that was developed by Dr. Peter Viccellio and his colleagues at the State University of New York at Stony Brook.

"This paper is another in a long series of wake-up calls about the dangerous practice of ‘boarding’ admitted patients in [emergency departments]," ACEP President Dr. David Seaberg said in a statement. "I just hope that hospital administrators and legislators smell the coffee. Their leadership is critical to changing the flow of patients from the front door of the emergency department to the inpatient floors of the hospital."

Emergency departments and hospitals can work together to find ways to improve efficiency, but several important ingredients are needed, Dr. Pines said. The Health Affairs article (2012;31:1757-66 [doi: 10.1377/hlthaff.2011.0786]) cites certain protocols that work, "but you need people to make them work," he said. "You need a strong leader in the ED who can get buy-in from the emergency group. ... You also need a supportive administration and medical staff to make it happen."

It is important to have a local quality improvement group whose members can look at the overall process by which patients get moved from the ED to inpatient services, and examine how patients are managed in the ED after they are admitted, Dr. Pines said. After the existing process is analyzed, hospital staff can identify and address the inefficiencies causing the delays.

The inefficiencies are highly particular to each facility, and often to each day and each shift in the ED and on inpatient wards, he said.