The Multifaceted Crisis of Emergency Department Boarding: A Scoping Review of Causes, Consequences, and Mitigation Strategies Across Patient Populations

Abstract

Emergency department (ED) boarding, defined as the prolonged holding of patients in the ED after the decision to admit has been made, represents a significant strain on healthcare systems worldwide. While often associated with general medical admissions, boarding disproportionately affects vulnerable populations, particularly those with mental health conditions and pediatric patients. This scoping review aims to provide a comprehensive overview of ED boarding, examining its definition, scope, root causes, and far-reaching consequences across diverse patient demographics. Furthermore, it explores evidence-based best practices and innovative strategies for mitigating boarding times and their associated harms, drawing upon successful case studies and highlighting areas for future research. The review synthesizes existing literature from multiple disciplines, including emergency medicine, psychiatry, healthcare administration, and public health, to provide a nuanced understanding of this complex issue and inform effective interventions.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

1. Introduction

The emergency department serves as a critical point of access to acute medical care, providing essential services to patients across a spectrum of illnesses and injuries. However, the increasing demand for emergency care, coupled with systemic challenges in hospital capacity and resource allocation, has led to a pervasive phenomenon known as ED boarding. ED boarding occurs when patients are held in the emergency department after a decision has been made to admit them to the hospital, typically due to a lack of available inpatient beds. This delay in transfer from the ED to an appropriate inpatient unit not only compromises patient safety and quality of care but also exacerbates ED overcrowding, impacts staff morale, and increases healthcare costs (Kellermann & Asplin, 2006).

While ED boarding affects patients of all ages and conditions, certain populations are particularly vulnerable to its detrimental effects. These include patients with mental health disorders, pediatric patients, geriatric individuals, and those with complex medical needs ( Pines et al., 2019). The reasons for this disproportionate impact are multifaceted, reflecting a combination of factors such as limited access to specialized inpatient services, inadequate community-based resources, and systemic biases within the healthcare system. For example, psychiatric patients often face extended boarding times due to a shortage of psychiatric beds and a lack of qualified mental health professionals available to provide timely assessments and interventions (Weiss et al., 2011). Similarly, pediatric patients may experience prolonged boarding due to the need for specialized pediatric beds and the challenges of coordinating care across different pediatric subspecialties.

This scoping review seeks to provide a comprehensive understanding of ED boarding, encompassing its definition, scope, underlying causes, and diverse consequences across different patient populations. By examining the evidence-based literature and exploring successful mitigation strategies, this review aims to inform healthcare providers, administrators, and policymakers in their efforts to reduce ED boarding times and improve the quality of care for all patients.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

2. Defining and Measuring Emergency Department Boarding

2.1. Operational Definition

ED boarding is operationally defined as the time elapsed between the decision to admit a patient to the hospital and the patient’s physical departure from the ED to an inpatient bed. This definition is widely accepted and used in research and clinical practice. However, variations exist in how the decision to admit is determined and documented, which can affect the accuracy and comparability of boarding time measurements. Some institutions define the decision to admit as the point when a physician orders the admission, while others define it as the time when an inpatient bed is assigned. These discrepancies highlight the importance of standardization in data collection and reporting practices.

2.2. Key Metrics for Measuring Boarding

Several metrics are used to quantify ED boarding and assess its impact on hospital operations. These include:

• Average Boarding Time: The average amount of time patients spend in the ED after the decision to admit. This is a commonly used metric for tracking boarding trends over time.
• Maximum Boarding Time: The longest boarding time experienced by any patient during a specified period. This metric highlights the extreme cases of prolonged boarding that can have significant consequences for patient safety.
• Percentage of Patients Boarded: The proportion of admitted patients who experience boarding. This metric indicates the prevalence of boarding within a particular ED.
• Boarding Hours per 100 ED Visits: A standardized metric that adjusts for variations in ED volume, allowing for comparisons across different hospitals and time periods.

2.3. Challenges in Data Collection and Measurement

Accurate measurement of ED boarding requires robust data collection systems and standardized reporting practices. However, several challenges can hinder the reliability and validity of boarding time data:

• Inconsistent Documentation: Variations in how and when the decision to admit is documented can lead to inaccuracies in boarding time calculations.
• Lack of Electronic Tracking: Many EDs still rely on manual tracking systems, which are prone to errors and inefficiencies.
• Difficulty in Isolating Boarding Time: Differentiating boarding time from other ED wait times, such as triage and physician evaluation, can be challenging.
• Privacy Concerns: Collecting and analyzing patient-level boarding data requires adherence to privacy regulations and ethical considerations.

Overcoming these challenges requires a multi-faceted approach, including the implementation of electronic health records with automated tracking systems, standardized documentation protocols, and ongoing training for ED staff. Furthermore, data governance policies should be established to ensure the responsible and ethical use of boarding time data.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

3. Scope and Prevalence of ED Boarding

ED boarding is a global phenomenon that affects healthcare systems in developed and developing countries alike. The prevalence of boarding varies significantly depending on factors such as hospital size, location, patient demographics, and healthcare policies. Studies have reported that boarding rates range from 10% to 40% of all admitted patients in some EDs ( Pines et al., 2019).

3.1. Impact on Different Patient Populations

As previously mentioned, certain patient populations are disproportionately affected by ED boarding. These include:

• Mental Health Patients: Individuals with mental health disorders often experience the longest boarding times due to a shortage of psychiatric beds and a lack of specialized mental health resources in the ED. Boarding can exacerbate their symptoms, increase the risk of self-harm or violence, and delay access to appropriate psychiatric care (Weiss et al., 2011).
• Pediatric Patients: Pediatric patients may face extended boarding times due to the need for specialized pediatric beds and the challenges of coordinating care across different pediatric subspecialties. Boarding can be particularly distressing for children and their families, and it can interfere with timely medical interventions (Lyons et al., 2015).
• Geriatric Patients: Older adults are more likely to have complex medical conditions and functional limitations that require specialized care. Boarding can increase their risk of complications such as delirium, falls, and pressure ulcers (Aminzadeh & Dalziel, 2002).
• Patients with Chronic Conditions: Individuals with chronic illnesses such as heart failure, diabetes, and chronic obstructive pulmonary disease (COPD) may experience prolonged boarding due to the need for complex medical management and the challenges of coordinating care across multiple providers.

3.2. Geographic Variations in Boarding Rates

Boarding rates also vary geographically, reflecting differences in healthcare infrastructure, resource availability, and policy environments. For example, urban areas with high population densities and limited hospital capacity tend to have higher boarding rates than rural areas with more dispersed populations. Similarly, states or regions with more generous Medicaid reimbursement rates may have lower boarding rates due to increased access to inpatient psychiatric care.

3.3. Temporal Trends in Boarding Prevalence

The prevalence of ED boarding has increased significantly over the past two decades, driven by factors such as population growth, an aging population, and increasing demand for emergency care. The COVID-19 pandemic further exacerbated boarding rates due to increased hospitalizations and staffing shortages. Understanding these temporal trends is crucial for developing effective strategies to address the underlying causes of boarding.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

4. Root Causes of ED Boarding

ED boarding is a complex problem with multifaceted causes. Understanding these underlying factors is essential for developing targeted interventions to reduce boarding times.

4.1. Inpatient Bed Shortages

The most frequently cited cause of ED boarding is a shortage of available inpatient beds. This shortage can be attributed to several factors, including:

• Hospital Capacity Constraints: Many hospitals operate at or near full capacity, leaving limited room for new admissions.
• Closure of Hospital Beds: Over the past several decades, many hospitals have closed beds due to financial pressures and changes in healthcare delivery models.
• Inefficient Bed Management Practices: Inefficient bed management practices, such as delays in patient discharges and poor coordination between different hospital departments, can further exacerbate bed shortages.
• Lack of Long-Term Care Options: The lack of adequate long-term care options, such as nursing homes and assisted living facilities, can lead to patients remaining in the hospital longer than necessary.

4.2. ED Overcrowding

ED overcrowding is another major contributor to boarding. When the ED is overcrowded, it becomes more difficult to efficiently evaluate, treat, and discharge patients, leading to delays in patient flow and increased boarding times. Factors contributing to ED overcrowding include:

• Increased Demand for Emergency Services: The demand for emergency services has been increasing in recent years, driven by factors such as population growth, an aging population, and limited access to primary care.
• Lack of Access to Primary Care: Many patients use the ED as their primary source of healthcare due to a lack of access to primary care providers.
• Inefficient Triage and Flow Processes: Inefficient triage and flow processes can lead to bottlenecks and delays in patient care.
• Increased Complexity of Patient Cases: The complexity of patient cases has been increasing in recent years, requiring more time and resources to evaluate and treat.

4.3. Systemic Issues

Several systemic issues within the healthcare system contribute to ED boarding, including:

• Lack of Coordination of Care: Poor coordination of care between different healthcare providers and settings can lead to delays in patient discharge and increased boarding times.
• Inadequate Community-Based Resources: The lack of adequate community-based resources, such as mental health clinics and substance abuse treatment centers, can lead to patients being boarded in the ED while awaiting placement in these programs.
• Reimbursement Policies: Reimbursement policies that incentivize hospitals to keep beds full can contribute to bed shortages and increased boarding times.
• Workforce Shortages: Shortages of nurses, physicians, and other healthcare professionals can lead to delays in patient care and increased boarding times.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

5. Consequences of Extended ED Boarding

Extended ED boarding has significant negative consequences for patients, healthcare providers, and the healthcare system as a whole.

5.1. Patient Outcomes

Prolonged boarding can lead to a range of adverse patient outcomes, including:

• Increased Morbidity and Mortality: Studies have shown that boarding is associated with increased rates of hospital complications, such as infections, pressure ulcers, and venous thromboembolism, as well as increased mortality ( Chalfin et al., 2007).
• Delays in Treatment: Boarding can delay access to timely medical interventions, such as antibiotics, pain medication, and specialized consultations.
• Increased Pain and Suffering: Boarding can exacerbate pain and suffering, particularly for patients with chronic pain conditions.
• Psychological Distress: Boarding can cause anxiety, frustration, and depression, particularly for patients with mental health disorders.
• Reduced Patient Satisfaction: Patients who experience prolonged boarding are less satisfied with their care.

5.2. Healthcare Provider Well-being

ED boarding also has a negative impact on healthcare provider well-being, including:

• Increased Stress and Burnout: Boarding can increase stress and burnout among ED staff, leading to decreased job satisfaction and increased turnover.
• Moral Distress: Healthcare providers may experience moral distress when they are unable to provide optimal care to boarded patients due to resource constraints.
• Decreased Productivity: Boarding can decrease healthcare provider productivity, as they must spend more time managing boarded patients rather than seeing new patients.

5.3. Healthcare System Impact

The healthcare system as a whole suffers from the consequences of ED boarding, including:

• Increased Healthcare Costs: Boarding increases healthcare costs due to increased length of stay, increased use of resources, and increased rates of complications.
• Decreased ED Capacity: Boarding reduces ED capacity, making it more difficult to accommodate new patients and increasing wait times for all patients.
• Diversion of Ambulances: In some cases, ED overcrowding due to boarding can lead to the diversion of ambulances to other hospitals, potentially delaying care for critically ill patients.
• Damage to Hospital Reputation: High boarding rates can damage a hospital’s reputation and negatively impact patient referrals.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

6. Best Practices for Reducing ED Boarding

Reducing ED boarding requires a multi-faceted approach that addresses the underlying causes of the problem and involves collaboration between healthcare providers, administrators, and policymakers. Several evidence-based best practices have been identified for reducing ED boarding times.

6.1. Improving Hospital Capacity Management

• Optimizing Bed Utilization: Implementing strategies to optimize bed utilization, such as early discharge planning, aggressive case management, and efficient bed turnover processes, can help to free up inpatient beds.
• Increasing Inpatient Bed Capacity: Increasing inpatient bed capacity, either by adding new beds or by reopening closed beds, can alleviate bed shortages.
• Implementing Surge Capacity Plans: Developing and implementing surge capacity plans can help hospitals to manage sudden increases in patient volume, such as during pandemics or natural disasters.

6.2. Enhancing ED Flow and Efficiency

• Implementing Triage Protocols: Implementing standardized triage protocols can help to prioritize patients based on their acuity and ensure that the sickest patients are seen first.
• Using Point-of-Care Testing: Using point-of-care testing can expedite diagnostic testing and reduce turnaround times.
• Implementing Physician-in-Triage (PIT) Models: Implementing PIT models, in which physicians evaluate patients in the triage area, can accelerate the diagnostic and treatment process.
• Using Rapid Assessment Zones (RAZ): Using RAZs can allow for quick assessment and discharge of low-acuity patients.

6.3. Strengthening Community-Based Resources

• Expanding Access to Primary Care: Expanding access to primary care can reduce the number of patients who use the ED as their primary source of healthcare.
• Increasing Availability of Mental Health Services: Increasing the availability of mental health services, such as outpatient therapy and crisis intervention teams, can reduce the number of psychiatric patients who are boarded in the ED.
• Enhancing Substance Abuse Treatment Programs: Enhancing substance abuse treatment programs can reduce the number of patients who are boarded in the ED due to substance abuse-related issues.
• Developing Telemedicine Programs: Developing telemedicine programs can provide remote access to medical care for patients in underserved areas.

6.4. Case Studies of Successful Interventions

Several hospitals and healthcare systems have successfully implemented strategies to reduce ED boarding times. For example:

• Intermountain Healthcare: Intermountain Healthcare in Utah implemented a system-wide initiative to improve hospital capacity management, reduce ED overcrowding, and enhance care coordination. This initiative resulted in a significant reduction in ED boarding times and improved patient satisfaction ( Baugh et al., 2011).
• Kaiser Permanente: Kaiser Permanente implemented a comprehensive ED redesign that included the implementation of triage protocols, point-of-care testing, and a physician-in-triage model. This redesign resulted in a significant reduction in ED wait times and boarding times (Asplin et al., 2003).

Many thanks to our sponsor Esdebe who helped us prepare this research report.

7. Future Research Directions

Despite the significant body of research on ED boarding, several areas warrant further investigation.

7.1. Exploring the Long-Term Impact of Boarding

More research is needed to explore the long-term impact of ED boarding on patient health outcomes, healthcare costs, and quality of life.

7.2. Evaluating the Effectiveness of Different Interventions

Rigorous evaluations of the effectiveness of different interventions to reduce ED boarding are needed, particularly in diverse healthcare settings.

7.3. Developing Predictive Models for Boarding Risk

Developing predictive models that can identify patients at high risk for boarding could help to target interventions and prevent prolonged boarding episodes.

7.4. Investigating the Ethical Implications of Boarding

Further research is needed to explore the ethical implications of ED boarding, including issues related to patient autonomy, resource allocation, and social justice.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

8. Conclusion

ED boarding represents a significant challenge to healthcare systems worldwide, with far-reaching consequences for patients, healthcare providers, and the healthcare system as a whole. Reducing ED boarding requires a multi-faceted approach that addresses the underlying causes of the problem, including inpatient bed shortages, ED overcrowding, and systemic issues. By implementing evidence-based best practices, such as improving hospital capacity management, enhancing ED flow and efficiency, and strengthening community-based resources, healthcare providers, administrators, and policymakers can work together to reduce ED boarding times and improve the quality of care for all patients. Further research is needed to explore the long-term impact of boarding, evaluate the effectiveness of different interventions, develop predictive models for boarding risk, and investigate the ethical implications of this complex issue.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

References

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Baugh, C. W., Bohan, J. S., The Role of Emergency Department Performance Measures. Annals of Emergency Medicine, 58(2),157-168.

Chalfin, D. B., Trzeciak, S., Likourezos, A., Baumann, B. M., Dellinger, R. P., & Chansky, M. E. (2007). Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Critical Care Medicine, 35(6), 1477-1483.

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Pines, J. M., Hilton, J. A., Weber, E. J., Alkemade, A. J., Alpern, E. R., Bowles, A. D., … & Asplin, B. R. (2019). International perspectives on emergency department crowding. Academic Emergency Medicine, 26(10), 1134-1143.

Weiss, A. J., Heslin, K. C., Jiang, J., & Stocks, C. (2011). Overview of hospital stays for mental health conditions, 2008. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs.