Ed Board Research Articles

Issue Information ‐ Ed Board

Issue Information ‐ Ed Board

Issue Information ‐ Ed Board

Issue Information ‐ Ed Board

A Retrospective Comparison of Emergency Department Throughput Before and After Instituting a Waiting Room Evaluation Process.

The COVID-19 pandemic has strained the healthcare system with emergency department (ED) boarding and workforce shortages. This prompted the need for strategies to evaluate and treat patients while they waited for an ED room. The objective is to describe a waiting room evaluation process and ED throughput in the setting of ED staffing shortages and boarding. This is a retrospective before and after cohort study evaluating ED throughput before and after initiation of the assessed waiting room (aWR) process. The aWR process is a joint effort by emergency clinicians and ancillary staff to evaluate and treat patients in the ED waiting room when no ED bed is available. Throughput data 6 months before and 6 months after institution of aWR was collected and analyzed. The arrival to provider time and the number of patients who left without being seen (LWBS) decreased with initiation of the aWR process. The remainder of throughput metrics remained unchanged. There was more ED boarding at Wisconsin sites during the aWR process period. The aWR process may minimize LWBS and improve arrival to provider time in the setting of staff shortages and more ED boarders. It may help other ED throughput metrics although numerous confounding factors make it difficult to make definitive conclusions. This process may be trialed during times of challenging healthcare landscape, such as pandemic conditions and with workforce shortages.

Emergency Department Boarding: Quantifying the Impact of ED Boarding on Patient Outcomes and Downstream Hospital Operations

Emergency Department Boarding: Quantifying the Impact of ED Boarding on Patient Outcomes and Downstream Hospital Operations

Issue Information ‐ Cover and Ed Board

Issue Information ‐ Cover and Ed Board

Characteristics and patient impact of boarding in the pediatric emergency department, 2018–2022

ObjectivesBoarding admitted patients in the emergency department is an important cause of throughput delays and safety risks in adults, though has been less studied in children. We assessed changes in boarding in a pediatric ED (PED) from 2018 to 2022 and modeled associations between boarding and select quality metrics. MethodsWe performed a retrospective analysis of PED patients admitted to non-psychiatric services, broken into four periods: pre-COVID-19 (Period I, 01/2018–02/2020), early pandemic (II, 03/2020–06/2021), COVID-19 variants (III, 07/2021–06/2022), and non-COVID respiratory viruses (IV, 07/2022–12/2022). Patients were classified as critical (intensive care units (ICU)) or acute care (non-ICU inpatient services) based on their initial bed request. We compared median boarding times with Kruskal-Wallis tests. We assessed the relationship between boarding time and hospital length-of-stay (LOS) through hazard regression models, and the association between boarding time and PED return visit, readmission, and patient safety events through adjusted logistic regressions. ResultsMedian PED boarding time significantly increased from Period I (acute: 2.4 h; critical: 3.0 h) to Period II (acute: 3.0 h, critical: 4.0 h) to Period III (acute: 4.4 h, critical: 6.6 h) to Period IV (acute: 6.2 h; critical: 9.5 h). On survival analysis, as boarding time increased, hospital LOS increased for acute admissions and decreased for critical admissions. Increased acute care boarding time was associated with higher odds of a filed safety report. ConclusionsSince July 2021, PED boarding time increased for admitted children across acute and critical admissions. The relationship between acute care boarding and longer hospital LOS suggests a resource-inefficient, self-perpetuating cycle that demands multi-disciplinary solutions.

Issue Information ‐ Ed Board

Issue Information ‐ Ed Board

Where’s my med? Improving patient-specific medication storage for emergency department boarders

BackgroundThere have been an increased number of patients boarding in the emergency department (ED) who often experience delays in receiving nonurgent medications not typically stocked in the ED automated dispensing cabinets (ADC). ObjectivesTo describe a quality improvement project designed to decrease the amount of time it takes nursing staff to obtain patient-specific medications for patients boarding in the ED at a community hospital. Practice descriptionPrior to this quality improvement project, standard practice was for pharmacy staff to send all medications to the ED based on inpatient cart fill lists, resulting in a 24-hour supply being sent at 1 time. Medications that were not immediately due were often misplaced by ED staff as there was no standard location to store them. Practice innovationA separate location for each examination room in the ED was created in 1 central ADC to store patient-specific medications. Pharmacy staff were instructed to load medications directly into the ADC for expected long-term behavioral health boarders. Nursing staff were instructed to place future doses in the newly created locations and were educated on how to locate medications utilizing the electronic medication administration record. Evaluation methodsED nursing staff timed how long it took them to obtain medications for 40 boarding patients before and after implementation of the quality improvement initiatives. ResultsThe postimprovement intervention decreased the amount of time it took to obtain medications for forty ED boarding patients by 66%, from an average of 37.7 minutes at baseline to 12.9 minutes postintervention. This was a statistically significant improvement via an unpaired t-test (P < 0.0001 with a 95% CI from 15.3 to 34.47). This was rechecked after 1 year and the improvement was sustained. ConclusionA multidisciplinary team-based quality improvement initiative was successful in reducing the time it took to obtain medications for ED boarding patients.

Issue Information ‐ Ed Board

Issue Information ‐ Ed Board

Clinicians' Insights on Emergency Department Boarding: An Explanatory Mixed Methods Study Evaluating Patient Care and Clinician Well-Being.

The aim of this study was to describe clinicians' insights into the quality and safety of patient care delivered to emergency department (ED) boarding patients, as well as clinician safety and satisfaction related to ED boarding. This was a single-site, mixed methods sequential explanatory study. Quantitative data were obtained from a cross-sectional survey sent to ED attending physicians, resident physicians, advanced practice providers, and nurses. Semistructured focus group interviews with a subsample of participants sought to add depth to the interpretation of survey data and identify areas of improvement in boarding care. Chi-square and Wilcoxon rank sum tests were used to evaluate for response differences between groups. Qualitative data were thematically coded and analyzed. A total of 94 questionnaires were obtained for a response rate of 34.1%. Clinicians reported that boarding highly contributed to the perception of burnout. All groups reported high rates of perceived verbal and/or physical abuse from boarding patients (86.8% of nurses, 41.1% of providers, p = 0.0002). A total of 39 clinicians participated in focus groups regarding boarding care, and six themes were identified, including patient safety concerns, lack of knowledge/resources/training, and poor communication. Key themes identified as possible solutions to improve care included standardization of care, proactive planning, and culture change. Clinicians identified many concerns regarding patient safety and the quality of care delivered to boarding patients and identified several areas for improvement. Clinicians also felt that boarding negatively affected their satisfaction and safety.

Issue Information ‐ Ed Board, ACTFL Officers Page

Issue Information ‐ Ed Board, ACTFL Officers Page

The effect of increasing emergency department observation volumes on downstream admission rates

Rising length of stay and inpatient boarding in emergency departments have directly affected patient satisfaction and nearly all provider-to-patient care metrics. Prior studies suggest that ED observation has significant clinical and financial benefits including decreasing hospitalization and length of stay. ED observation is one method long employed to shorten ED length of stay and to free up inpatient beds, yet many patients continue to be admitted to the hospital with an average hospital length of stay of only one day. The objectives of this study were to evaluate whether vigorous tracking and provider reviews of one day hospital admits affected the utilization of ED observation and whether this correlated with significant change in rates of admission from observation status.Between September 2020 and May 2021, in a tertiary care hospital with an annual ED volume of 55,0000, chart reviews of 24-h inpatient discharges were initiated by two senior EM faculty to determine perceived suitability for ED observation. Non-punitive email reviews were then initiated with ED attending providers in order to encourage evaluation of whether these patients would have benefitted from being placed into observation. We then analyzed ED observation patient volumes and subsequent admission rates to the hospital from ED observation and compared these numbers to baseline ED observation volume and admission rates between September 2018 and May 2019.A total of 1448 reviews were conducted on 24-h discharges which correlated with an increase in utilization of ED observation from 11.77% (95% CI [11.62, 12.31]) of total ED volume in our control period to 14.21% (95% CI [13.84, 14.58]) during the study period. We found that the overall admission rate from ED observation increased from 20.12% (95% CI [18.97, 21.26]) baseline to 23.80% (95% CI [22.60, 25.00]) during the same time periods.Our data suggest that increasing the total number of patients placed into observation by 21% correlated with a relative increase in admission rates from ED observation by 18%. This would suggest that our efforts to potentially include more patients into our observation program led to a significant increase in subsequent admission rates. There is likely a balance that must be struck between under- and over-utilization of ED observation, and expanding ED observation may be an effective solution to hospital boarding and ED overcrowding.

Issue Information ‐ Cover and Ed Board

Issue Information ‐ Cover and Ed Board

Issue Information ‐ Ed Board

Issue Information ‐ Ed Board

An initiative to reduce psychiatric boarding in a Cape Town emergency department.

Psychiatric boarding in Emergency Departments (ED) is a global challenge which results in long ED length of stays (LOS) with significant consequences on patient care and staff safety. This study investigated the impact of an initiative to reduce psychiatric boarding on LOS and readmission rate, as well as explored the relationship between boarding times and LOS. This study was conducted at Mitchells Plain Hospital, a large district-level hospital in Cape Town. This cross-sectional study collected data for 24 months, which included a 9-month period prior to the initiative and 16 months thereafter. Data were collected retrospectively from official electronic patient registries. The initiative comprised of inpatient hallway boarding as a full-capacity protocol with the accompanying capacitation of psychiatric wards to accommodate the additional burden. The initiative was associated with a decrease of 95% (p < 0.001) in boarding time, 13% (p < 0.001) in ward LOS and 25% (p < 0.001) in hospital LOS. Ward LOS were found to be independent of ED boarding times. The readmission rate increased from 12% to 18% post intervention. The initiative resulted in a sustainable improvement in boarding times and LOSs. The observational nature of this study precludes concrete conclusions and further investigations into psychiatric inpatient hallway boarding are recommended. Inpatient hallway boarding could be a feasible option to reduce the risk. Psychiatric boarding times in the ED are independent of ward LOS, rendering it devoid from any value from a lean and economic perspective.

Issue Information ‐ Ed Board

Issue Information ‐ Ed Board

Analysis of health inequities in transfers of admitted patients from an academic emergency department to partner community hospital

BackgroundMany academic medical centers (AMC) transfer patients who require admission but not tertiary care to partner community hospitals from their emergency departments (ED). These transfers alleviate ED boarding but may worsen existing healthcare disparities. We assessed whether disparities exist in the transfer of patients from one AMC ED to a community hospital General Medical Service. MethodsWe performed a retrospective cohort study on all patients screened for transfer between April 1 and December 31, 2021. During the screening process, the treating ED physician determines whether the patient meets standardized clinical criteria and a patient coordinator requests patient consent. We collected patient demographics data from the electronic health record and performed logistic regression at each stage of the transfer process to analyze how individual characteristics impact the odds of proceeding with transfer. Results5558 patients were screened and 596 (11%) ultimately transferred. 1999 (36%) patients were Black or Hispanic, 698 (12%) had a preferred language other than English, and 956 (17%) were on Medicaid or uninsured. A greater proportion of Black and Hispanic patients were deemed eligible for interhospital transfer compared to White patients and a greater proportion of Hispanic patients completed transfer to the community hospital (p < 0.017 after Bonferroni correction). After accounting for other demographic variables, patients older than 50 (OR 1.21, 95% CI 1.04–1.40), with a preferred language other than English (OR 1.27, 95% CI 1.00–1.62), and from a priority neighborhood (OR 1.38, 95% CI 1.18–1.61) were more likely to be eligible for transfer, while patients who were male (OR 1.50, 95% CI 1.10–2.05) and younger than 50 (OR 1.85, 95% CI 1.20–2.78) were more likely to consent to transfer (p < 0.05). ConclusionHealth disparities exist in the screening process for our interfacility transfer program. Further investigation into why these disparities exist and mitigation strategies should be undertaken.

Issue Information ‐ Cover and Ed Board

Issue Information ‐ Cover and Ed Board

Issue Information ‐ Ed Board

Issue Information ‐ Ed Board

Issue Information ‐ Ed Board

Issue Information ‐ Ed Board