ED Boarding

Health care delivery related to the “boarding” of emergency department (ED) patients is a critical area of quality of care improvement for emergency medicine. Boarding is the process of holding patients in the ED for extended periods of time after an inpatient bed request is made (Asplin, et al., 2003). Boarding is widespread and interrelated to ED crowding. The Institute of Medicine (IOM) in 2006 reported that, ‘”boarding not only compromises the patient’s hospital experience, but adds to an already stressful work environment, enhancing the potential for errors, delays in treatment, and diminished quality of care’’ (Havens & Boroughs, 2006). This paper examines quality of care for boarded ED patients using Donabedian’s framework of structures,
processes, and outcomes for quality evaluation. Additionally, it outlines the use of short-term observation units as a practical solution to improving quality of care for boarded ED patients.
Donabedian’s framework divides factors impacting quality into structures, processes, and outcomes and provides a theoretical framework to assess quality of care for boarded patients. Key considerations are made regarding the correlation of these three measures as they relate to quality issues. In the context of boarding in emergency departments, potential structural impediments include physical environments, provider training and skill sets, and handoffs inherent in providing care to boarded ED patients. Structural inadequacies within an ED may compromise processes such as patient diagnosis, treatment, and medication administration. These structural and processes weaknesses may ultimately lead to poor outcomes from a patient including the delivery of timely, equitable, and effective medical care.
According to Donabedian, structure is the physical setting in which care takes place and the qualification and training of the care providers (Donabedian, 2005).
Unstable patients have the priority to ED rooms. Typically, this means less critical boarded patients are often placed in hallways to make more ED rooms available for patients while they wait for admission to an inpatient unit. This setting subjects boarded patients to a disruptive and unpredictable environment. There are also inherent structural differences between the care provided to boarded patients compared to the care in inpatient units. First, emergency physicians (EPs) and nurses lack the proper skill set to manage boarded patients. Care in the ED focuses more on stabilization, disposition, and preliminary diagnosis than on inpatient observation and management (Hockberger, et al., 2005). Second, new patients act as a distraction and are higher priority for ED staff compared to boarded patients. This level of distraction increases potentially dangerous handoffs between EPs as compared to an inpatient service setting. According to the Institute of Medicine’s safety publication, To Err Is Human: Building a Safer Health System, emergency departments (EDs) are susceptible to “high error rates with serious consequences” (Havens & Boroughs, 2006). These structural differences may explain why boarded patients could experience compromised quality of
care.
Many potential pathways link the above structural problems with ways that processes are compromised for boarded patients in terms of observation, diagnosis, and treatment.
Distracted ED staff without the proper skill sets may lead to delays or errors in diagnosis and treatment, including delayed or omitted laboratory testing, procedures, and medication administration. In a study conducted by Penska, communication errors were the root cause in about 70% of cases when sentinel events occur (Pesanka, et al., 2009). Medication safety is a critical area to consider when examining process measures related to boarded ED patients. The risk of medication errors in ill boarded ED patients can lead to poor patient outcomes such as a decrease in blood pressure and oxygenation, heart arrhythmias, and multi-organ dysfunction (Richardson & Mountain, 2009). This serves as an example of process measures directly affecting the health outcomes of boarded ED
patients.
Patient outcomes are ultimately affected by structures and processes in the Donabedian framework. The IOM defines quality according to several components including timeliness, equitability, efficiency, and patient satisfaction (IOM, 2001). Questions of timeliness and equitability arise when comparing the demographic characteristics of boarded patients. Research has found that certain minority groups are systematically boarded for longer periods including black, female, elderly, and psychiatric patients. Specifically, compared to their white counterparts, black boarded patients were at higher risk for ED length of stay greater than 6 hours (odds ratio [OR] = 1.42, 95% confidence interval [CI] = 1.01 to 2.01) (Pines, Localio, & Hollander, 2009). Boarding also creates deficiencies in efficiency related to timeliness. In a 2002 Government Accountability Office survey (GAO), 31% of responding hospitals reported that three-fourths of patients spent 2 hours or more boarding in the ED and nearly 20% reported patients boarding for 8 hours or more. Furthermore, hospitals with longer wait times also saw an overall decrease in patient satisfaction scores in the ED (GAO, 2003).
From the perspective of an administrator, in order to improve quality of care delivered to boarded ED patients, the issues mentioned related to systems, processes, and outcomes must be solved. A long-term solution geared toward decreasing the number of boarded patients within an ED would be creating short-term observation units which are separate from the ED. Observation units are designated areas within a hospital, adjacent to the emergency department, that provide an alternative to discharge or hospital inpatient admission for the emergency department patient who may benefit from an extended observation period (Crenshaw, Lindsell, Storrow, & Lyons, 2006). The units would be staffed by trained inpatient personnel. Research has shown that potential benefits of observation units include reduced boarding which would also cause numerous improvements in systems, processes, and outcome measures including improved patient and provider satisfaction, shorter lengths of stay, decreased medical liability risks, and efficient patient flow (Ross, Hemphill, Abramson, Schwab, & Clark, 2010). Ultimately, when properly utilized, observation units are an effective solution to reduce inefficiencies in the quality of care of boarded ED patients.
Boarded ED patients and resulting overcrowding has many other potential detrimental effects including decreased appropriateness of care, diagnosis and treatment and most importantly, greater risk for poor outcomes. The three-part approach by Donabedian makes quality assessment possible assuming structures influence processes which influence outcomes. Observation units serve as one possible solution to reduce the frequency of boarded patients in ED and improve their overall quality of care.