128 The Effects of Boarding on Traditional and Provider in Triage Models

Abstract

Boarding has been associated with longer hospital lengths of stay, decreased patient satisfaction, and adverse quality and safety outcomes. However, to date there is little research on how closely boarding is associated with its effects on emergency department intake and whether specific intake patient flow models can mitigate the effects of boarding. We hypothesized that there would be a significant association between emergency department boarding and operational efficiency metrics and that this effect would be partially mitigated by a provider-in-triage (PIT) intake flow model. This was a retrospective, observational study of operational data related to 275,981 ED visits over 955 days (July 1 2015 to February 9th 2018) at a single tertiary referral academic level 1 trauma center. One year of operational data was collected before a PIT model was implemented in the ED. The key outcome variables included D2P time, total ED length of stay, active care time, and boarding times (A2D60). Boarding was defined as the time spent in the ED until ED departure in excess of 60 minutes since bed request. Active care time was defined as LOS of discharged patients - D2P time, a measure of efficiency of care after first being seen by a provider. Descriptive statistics are reported on the outcome variables, quartile regressions, and adjustments for overall ED median volume were all used to analyze the association between outcome variables. Statistical analyses were conducted using SAS (version 9.4). There were 250 pre PIT implementation days and 705 post. The overall median number of patients seen daily in the ED was 291 (IQR: 273, 306). The admission rate was 28.7% (95% CI: 28, 29.4), this did not change between pre and post PIT implementation. The median time of D2P significantly decreased pre to post PIT implementation (t (738) = 15.6; p < 0.001); but did not significantly increase the time from disposition to departing the ED (t (738) = 1.63, p = 0.06). Across the data collected there was a positive unadjusted correlation between A2D60 and D2P (r = 0.19; p = 0.01), with an increase of 1 minute in D2P for every 4 minutes of A2D60. In a regression model, after adjusting for median patient volume, and phase of PIT (pre to post), the effect of A2D60 on D2P was still significant (β = 0.13; p < 0.001), indicating a continued linear increase in D2P with overall increase in boarding. Pre PIT, A2D60 had no significant effect on median active care time; post PIT implementation every 9.1 minute increase in A2D60 resulted in a 1-minute increase in active care time above the median active care time (p=0.001). In this single center study, while the PIT intake model did significantly decrease D2P, boarding time still significantly affected D2P in both intake models. Boarding also results in increases in the active care time of discharged patients, suggesting boarding has downstream effects reducing the efficiency of ED patients who would otherwise not be subjected to boarding. A PIT intake model results in lower D2P times and shorter ED LOS but is unable to mitigate the effects of boarding.