Longer Boarding Times Predict Patient Processing in ED

Heidi Splete

October 10, 2022

Each additional 10 minutes of boarding in the emergency department (ED) was associated with a 0.8-minute increase in door-to-provider time, on the basis of data from nearly 900 facilities presented at the American College of Emergency Physicians (ACEP) 2022 Scientific Assembly.

The study was important to conduct at this time because ED boarding is significantly limiting ED physicians to provide optimal care, said Camila Tyminski, MD, of Brown University, Providence, Rhode Island, who presented the findings at the meeting.

"Boarding had steadily been rising prior to the COVID-19 pandemic due to increased ED use. As our data show, boarding had a detrimental impact on ED throughput measures, including increased door to provider time, increased length of stay of the patient discharged from the ED, and increased rate of patients that left before completion of treatment," she said.

"It was important to understand these trends prior to 2019-2020 because the COVID-19 pandemic and national nursing shortage have drastically worsened boarding. This study provided a framework for future studies on boarding across ED’s nationally since the start of the pandemic," she added.

"Post-pandemic, we have hit a crisis point," lead author Anthony Napoli, MD, also of Brown University, told Medscape Medical News. "Boarding is largely a hospital capacity problem but one key fix germane to EM [emergency medicine] is the provider in triage model (PIT). While PIT has been shown to improve efficiency of ED care, a single institution study demonstrated that it was unable to mitigate the effects of boarding. The study of the association of boarding and efficiency of ED operations and intake needed to be shown on a national scale," he said.

The researchers reviewed cross-sectional ED operational data from the ED Department Benchmarking Alliance (EDBA), a voluntary database that includes self-reports of operational metrics from approximately half of EDs in the United States.

The data set included 892 EDs;  freestanding and pediatric EDs as well as those with missing boarding data were excluded.

The primary outcome was boarding time, door-to-provider time (D2P), length of stay for discharged patients (LOSD) and the percentage of patients who left the hospital before completing treatment (LBTC).

In a multivariate analysis, increased boarding time was significantly associated with longer D2P time, LOSD time, and rates of LBTC.

Overall, D2P and LOSD increased by 0.8 minutes and 2.8 minutes, respectively, for each additional 10 minutes of boarding time. LBTC rates increased by 0.1% for each additional 10 minutes of boarding time.

However, boarding did not have a significant impact on operational metrics among hospitals with fewer than 20,000 visits per year.

Although more research is needed, the results indicate that boarding reduces the throughput of nonboarded patients at a ratio of approximately 4:1. The limited impact of ED efficiency measures on operations highlights the need for hospital-based solutions to boarding, Tyminski concluded.

"Overall, we expected that there would be an association between boarding and reductions in ED intake and operational efficiency," said Napoli in an interview. "However, we were surprised the relationship continued to be as strong in a national study of nearly a quarter of all EDs, as it did in our prior local study," he said. "Every 10 minutes of boarding in an ED is associated with an approximate 0.1% increase in LWBS and a 3-minute increase in LOSD. Extrapolating this association across the country, we predicted that nearly one million patients may have potentially not received ED care due to boarding," he explained. "Not only does this potentially have a huge impact on hospital finances, but also the overall health of our patients," he added.

The key takeaway from the study is that boarding is a hospital capacity management issue, said Napoli. Hospital leadership must be directly involved to in plans to mitigate or eliminate it to the extent possible; until then, boarding will continue to result in inefficient ED operations, he explained.

"As ED providers, we are limited in what we can do, but one area where we might be able to make the most impact is to optimize the care and throughput of the LOSD patients," Tyminski said. More research is needed to see if interventions to reduce boarding correspond with equivalent improvements in emergency department intake and improved ED throughput, she noted.

The study received no outside funding. The researchers disclosed no relevant financial relationships.

American College of Emergency Physicians (ACEP) 2022 Scientific Assembly. Presented October 1, 2022. Abstract 200

Heidi Splete is a freelance medical journalist with 20 years of experience.

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