Impact on Length of Stay of a Hospital Medicine Emergency Department Boarder Service
BACKGROUND: It is not known whether delivering inpatient care earlier to patients boarding in the emergency department (ED) by a hospitalist-led team can decrease length of stay (LOS).
OBJECTIVE: To study the association between care provided by a hospital medicine ED Boarder (EDB) service and LOS.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective cross-sectional study (July 1, 2016 to June 30, 2018) conducted at a single, large, urban academic medical center. Patients admitted to general medicine services from the ED were included. EDB patients were defined as those waiting for more than two hours for an inpatient bed. Patients were categorized as covered EDB, noncovered EDB, or nonboarder.
INTERVENTION: The hospital medicine team provided continuous care to covered EDB patients waiting for an inpatient bed.
PRIMARY OUTCOME AND MEASURES: The primary outcome was median hospital LOS defined as the time period from ED arrival to hospital departure. Secondary outcomes included ED LOS and 30-day ED readmission rate.
RESULTS: There were 8,776 covered EDB, 5,866 noncovered EDB, and 2,026 nonboarder patients. The EDB service covered 59.9% of eligible patients and 62.9% of total boarding hours. Median hospital LOS was 4.76 (interquartile range [IQR] 2.90-7.22) days for nonboarders, 4.92 (IQR 3.00-8.03) days for covered EDB patients, and 5.11 (IQR 3.16-8.34) days for noncovered EDB (P < .001). Median ED LOS for nonboarders was 5.6 (IQR 4.2-7.5) hours, 20.7 (IQR 15.8-24.9) hours for covered EDB, and 10.1 (IQR 7.9-13.8) hours for noncovered EDB (P < .001). There was no difference in 30-day ED readmission rates.
CONCLUSION: Admitted patients who were not boarders had the shortest LOS. Among boarded patients, coverage by a hospital medicine-led EDB service was associated with a reduced hospital LOS.
© 2020 Society of Hospital Medicine
Emergency department (ED) crowding and boarding of patients awaiting admission to the hospital (ED boarding) are growing problems with important clinical care and public safety implications.1-4 Increased ED boarding times have been associated with lower patient satisfaction, inadequate care of critically ill patients, adverse events, and increased mortality.3,5-7 Furthermore, ED boarding can diminish the ED’s ability to evaluate new patients.5,8,9 ED boarding is more severe in hospitals with high inpatient occupancy with resultant disproportionate burden on large urban institutions.2,4,5,10
Earlier studies suggest, but have not consistently shown, an association between longer ED length of stay (LOS) and longer overall hospital LOS.5 This association implies that the additional time spent in the ED waiting for a bed does not meaningfully contribute to advancing the required inpatient care. Thus, this waiting time is “dead time” that is added to the overall hospital duration.
The complexity and the volume of medical patients boarding in the ED can challenge the resources of an already overtaxed ED staff. Potential solutions to mitigate ED boarding of medicine patients generally focus on reducing barriers to timely movement of patients from the ED to an inpatient unit.1,3,11-13 Ultimately, these barriers are a function of inadequate hospital capacity (eg, hospital beds, staffing) and are difficult to overcome. Two primary strategies have been used to reduce these barriers. One strategy focuses on shifting inpatient discharge times earlier to better match inpatient bed supply with ED demand.14-19 Another common strategy is utilizing inpatient attendings to triage and better match bed needs to bed availability.20-22
A separate area of interest, and the focus of this study, is the deployment of inpatient teams to hasten delivery of inpatient care to patients waiting in the ED.8,23 One institution implemented an “ED hospitalist” model.23 Another created a hospital medicine team to provide inpatient medical care to ED boarder patients and to lend clinical input to bed management.8
At our large, urban academic medical center, the Department of Medicine in collaboration with the Department of Emergency Medicine created a full-time hospital medicine team dedicated to providing care in the ED for patients awaiting admission to a general medicine unit. We present our multiyear experience with this ED-based hospital medicine team. We hypothesized that this new team would expedite inpatient care delivery to medical boarder patients, thereby reducing the overall hospital LOS.
METHODS
Study Setting and Design
This retrospective cross-sectional study, approved by the Institutional Review Board, was conducted at a 1,011-bed academic medical center in the northeast United States. The study period was July 1, 2016 through June 30, 2018, which was divided into Academic Year 16 (AY) (July 1, 2016 to June 30, 2017) and AY17 (July 1, 2017 to June 30, 2018).
