Implementation of the Discharge Hospitality Center to Reduce Emergency Department Boarding

A Quality Improvement Project

Karin B. Smith


Nurs Econ. 2018;36(6):282-290. 

In This Article

Abstract and Introduction


Between 1999 and 2009, there was a nationwide increase in emergency department (ED) visits, ranging from 32% to 43% (Carter, Pouch, & Larson, 2014; Pallin, Allen, Espinola, Camargo, & Bohan, 2013). During the same time period, hospital and intensive care unit admissions originating from the ED increased from 13.2 to 17.1 million and from 1.4 to 2.2 million, respectively (Carter et al., 2014). Overall, approximately 44% of all hospitalizations originate from the ED and overcrowding of acutely ill patients in the ED poses a significant patient safety concern at the same time demand for emergency resources is greater than the available resources (Carter et al., 2014; Pallin et al., 2013). Additionally, delays in moving admitted patients (known as boarders) into the hospital exacerbate ED overcrowding and contribute to poor quality care (Pallin et al., 2013).

In response for the high demand of healthcare services, many hospitals are forced to be creative in redesigning patient flow to optimize hospital capacity. ED crowding and boarding of admitted patients has become the focus of academic medicine, government, and regulatory agencies, including the American College of Emergency Physicians (ACEP), United States Congress, Institute of Medicine (IOM), The Joint Commission, Centers for Medicare & Medicaid Services (CMS), U.S. Department of Health and Human Services, and Centers for Disease Control and Prevention (ACEP, 2009; IOM, 2007; McHugh, Van Dyke, McClelland, & Moss, 2011; Pitts, Niska, Xu, & Burt, 2008).

Concern for improving patient care, quality, and safety has been the catalyst for performance improvement initiatives, such as The Joint Commission's patient flow standards, known as LD.04.03.11, which outlines nine elements of performance that address leadership's responsibility and authority to evaluate patient flow and take necessary actions (Calloway, 2012). The Joint Commission recommends "boarding time frames not exceed four hours in the interest of patient safety and quality of care" (2013, p. 1). The Joint Commission 4-hour boarding timeframe is to be used as a guide to help healthcare organizations set realistic goals for patient flow and is only recommended and not required for accreditation.

Additionally, CMS requires hospitals to report ED crowding measures such as patient median time from ED arrival to ED departure for discharged patients, door-to-diagnostic evaluation by a qualified medical professional, patient left before being seen, median time from ED arrival to ED departure for admitted patients, and median time from admit decision time to time of departure for admitted patients (McHugh et al., 2011). Hospitals are required to report these measures to CMS to receive full Medicare payment, and ultimately, these measures will be reported publicly on Medicare's Hospital Compare website (McHugh et al., 2011).

The IOM's Crossing the Quality Chasm: A New Health System for the 21st Century (2001) drew attention to critical quality problems in health care and provides a framework for assessing the performance of emergency care through six quality aims: safe, effective, patient-centered, timely, efficient, and equitable. The IOM (2007) states the current U.S. emergency care system fails the public in achieving those six quality aims, and progress for implementing needed reforms has been slow due to deeply engrained cultural barriers, lack of consistent accountability, and minimal public understanding of the importance and limitations of emergency care. Further, the IOM Committee on the Future of Emergency Care in the United States Health System was formed in 2003 after the U.S. Congress requested the IOM to examine the emergency care system (IOM, 2007). IOM's Hospital-Based Emergency Care: At the Breaking Point, revealed EDs were seriously overcrowded, with patients boarding for excessive periods of time (ACEP, 2009).