Longer Boarding Times Research Articles

Impact of boarding time on in-hospital mortality in patients with cancer presenting to the emergency department.

11036 Background: Longer emergency department (ED) boarding times for admitted patients is associated with increased morbidity and mortality.1 While research over the years has shown an association between boarding time to mortality in a variety of patient demographics, no specific research has been explored in a cancer population. Patients with cancer visit the emergency department frequently and have a high rate of admission compared to other patients.2 This study evaluates boarding times and mortality rates in patients presenting to an oncologic ED. Methods: A retrospective analysis was performed on 183,524 ED visits located at a comprehensive cancer center between March 2016 and December 2022. Eligibility criteria included patients 19 years and older admitted to the hospital excluding direct intensive care unit admission. Boarding time was defined from the time the physician made an order to admit to the hospital to the time of ED departure. Demographics and clinical characteristics were examined using descriptive statistics. Categorical data was analyzed using chi-square test and continuous variables employed the nonparametric Mann–Whitney U test. Boarding time was grouped into quartiles. Univariate and multivariable logistic regression analyses examined clinical factors, including boarding time and in-hospital mortality. Results: The eligible number of visits supporting the study equaled 83,629. Overall median boarding time was 2.7 hours (interquartile range: 1.5–5.1 hours) and in-hospital mortality was 5.5% (n=4607). Longer boarding time was significantly associated with in-hospital mortality. Patients with boarding time ≥5.1 hours had 1.19 (95% confidence interval [95%CI]: 1.09-1.30; P<0.001) odds of in-hospital mortality when compared to the reference group (boarding time <1.5 hours) when controlling for other risk factors including comorbidities and emergency severity index (ESI) between 1 through 5. Similar results were observed for patients with boarding times of ≥1.5- <2.7 hours and ≥2.7- <5.1 hours with odds ratio of 1.12 (95%CI: 1.02-1.22; P=0.013) and 1.11 (95%CI: 1.02-1.21; P=0.020), respectively. Higher Charlson comorbidity index and levels 1 and 2 ESI were also associated with poor survival outcome (P<0.001 for both). Conclusions: This study found an association between boarding time and in-hospital mortality in cancer patients presenting to the ED. Patients with longer boarding times were likely to experience mortality during their hospital admission. High comorbidity score and high-risk ESI were also identified as risk factors for poor survival outcome. These results emphasize the need for improved strategies to expedite the admission process and optimize care for cancer patients in the ED to reduce mortality rates. Further research and interventions targeting reduction in boarding times are warranted to improve outcomes for this vulnerable population.

A targeted initiative to discharge surgical patients earlier in the day is associated with decreased length of stay and improved hospital throughput

BackgroundThe timing of inpatient discharges can impact hospital throughput with later discharges leading to decreased patient satisfaction, increased length of stay (LOS), and longer boarding times. MethodsA 12-month targeted intervention that included both pre-operative and inpatient components was implemented across all surgical inpatient services to increase the proportion of patients discharged by noon. ResultsDischarge by noon rates increased from 14.3% to 21.5% during the 12-month initiative (p < 0.01). The case mix index adjusted LOS (aLOS) decreased from 2.17 to 2.02 days (p < 0.01). ED, PACU, and ICU boarding times were all significantly lower during the initiative (p < 0.01, p < 0.01, p = 0.03 respectively). ConclusionsA targeted initiative to discharge surgical patients earlier resulted in a 50% increase in the proportion of patients discharged by noon. Associated with this finding were improvements in hospital throughput as measured by aLOS and boarding times in the ED, ICUs, and PACU.

National Differences in Regional Emergency Department Boarding Times: Are US Emergency Departments Prepared for a Public Health Emergency?

Boarding admitted patients decreases emergency department (ED) capacity to accommodate daily patient surge. Boarding in regional hospitals may decrease the ability to meet community needs during a public health emergency. This study examined differences in regional patient boarding times across the United States and in regions at risk for public health emergencies. A retrospective cross-sectional analysis was performed by using 2012 ED visit data from the American Hospital Association (AHA) database and 2012 hospital ED boarding data from the Centers for Medicare and Medicaid Services Hospital Compare database. Hospitals were grouped into hospital referral regions (HRRs). The primary outcome was mean ED boarding time per HRR. Spatial hot spot analysis examined boarding time spatial clustering. A total of 3317 of 4671 (71%) hospitals were included in the study cohort. A total of 45 high-boarding-time HRRs clustered along the East/West coasts and 67 low-boarding-time HRRs clustered in the Midwest/Northern Plains regions. A total of 86% of HRRs at risk for a terrorist event had high boarding times and 36% of HRRs with frequent natural disasters had high boarding times. Urban, coastal areas have the longest boarding times and are clustered with other high-boarding-time HRRs. Longer boarding times suggest a heightened level of vulnerability and a need to enhance surge capacity because these regions have difficulty meeting daily emergency care demands and are at increased risk for disasters. (Disaster Med Public Health Preparedness. 2016;10:576-582).

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Introduction: Critically ill patients are a growing population in U.S. Emergency Departments (ED),requiring increasing physician time,higher intensity of treatments,and longer boarding times in the ED.The longer boarding times may be associated with increased mortality, as the patients are in a gray zone of uncertainty regarding the responsible physician team,management and communication.Inadequate communication between teams magnifies the potential for serious medical errors.Our project was designed to improve the quality of communication and safety of patient care by instituting a formal evaluation and handoff process between the ED physician/nurse team and the evaluating critical care team. The project goals were completion of an interdepartment handoff which includes identifying the responsible team, delineating exact management plans, and targeting the timeframe for ICU decision.The goal measures were improved time to critical care decision and reduction of ED boarding time. Methods: For this quality improvement project,we assembled an interprofessional team including physicians and nurses from Emergency Medicine,Critical Care Medicine and Internal Medicine to implement a novel policy for evaluation and management of critically ill patients in the ED.An initial survey of ED nurses was performed. Education of Emergency Medicine and Critical Care was initiated and a time frame of 90 minutes from ED call to ICU decision was established.A formal written handoff was implemented:Part A was the initial request for ICU evaluation which required a face-to-face handoff from ED to critical care;following critical care team assessment, Part B documented a huddle with the ED team to articulate the decision and management plans.All written handoff documents were reviewed and the median time to decision was recorded. ED boarding times for the period were obtained and compared to the prior year.An extensive education program included all disciplines. Results: Baseline survey of ED nurses revealed: 56% believed there was thorough transfer of information to critical care team, 29% believed the responsible physician was clearly identified and 24% believed a clear plan of care was communicated to the nurse. Baseline median time from ED call for ICU evaluation to ICU decision was 130 minutes. Following implementation of the handoff policy: for the 4 month period, 475 ED-critical care team handoff/huddles were completed and documented, comprising 90% of critical care evaluations in the ED. Median time to ICU decision decreased from 130 to 86 minutes. Compared to year 2012, during the intervention period, median ED boarding time from ICU decision to discharge to ICU decreased from 238 to 181 minutes. Conclusions: This interprofessional and interdepartment quality and safety project was successful in implementing a formal in-person written handoff and team huddle for all critically ill patients in the ED.Our initial survey of nurses indicated deficits in communication. The education and handoff process resulted in a reduction in time to ICU decision and reduced ED boarding times. This project led to improved communication among physicians and nurses,improved communication between Emergency Department and ICU staff, and improved staff satisfaction. We believe that this model helped to build relationships and improve accountability and responsibility for critically ill patients in the ED.

Boarding Admitted Children in the Emergency Department Impacts Inpatient Outcomes

This study aimed to assess the relationship between boarding of admitted children in the emergency department (ED) and cost, inpatient length of stay (LOS), mortality, and readmission. This was a retrospective study of 1,792 pediatric inpatients admitted through the ED and discharged from the hospital between February 20, 2007 and June 30, 2008 at a major teaching hospital with an annual ED volume of 40,000 adult and pediatric patients.The main predictor variable was boarding time (time from admission decision to departure for an inpatient bed, in hours). Covariates were patient age, payer group, times of ED and inpatient bed arrival, ED triage acuity, type of inpatient service, intensive care unit admission, surgery, and severity of inpatient illness. The main outcome measures, cost (dollars) and inpatient LOS (hours), were log-transformed and analyzed using linear regressions. Secondary outcomes, mortality and readmission to the hospital within 72 hours of discharge, were analyzed using logistic regression. Mean ED LOS for admitted patients was 9.0 hours. Mean boarding time was 5.1 hours. Mean cost and inpatient LOS were $9893 and 147 hours, respectively. In general, boarding time was associated with cost (P < 0.001) and inpatient LOS (P = 0.01) but not with mortality or readmission. Longer boarding times were associated with greater inpatient LOS especially among patients triaged as low acuity (P = 0.008). In addition, longer boarding times were associated with greater probability of being readmitted among patients on surgical services (P = 0.01). Among low-acuity and surgical patients, longer boarding times were associated with longer inpatient LOS and more readmissions, respectively.