Prolonged Boarding Times Research Articles

From Their Perspective: Pediatric Patients With Acute Mental Health Needs and Prolonged Emergency Department Stays.

The pediatric emergency department (PED) is experiencing a rising volume of patients with mental health concerns, leading to prolonged boarding times and delays in initiating active therapeutic plans. A paucity of research exists for the self-reported pediatric patient experience during such boarding. To inform more individualized and patient-centered PED care for patients boarding for mental health admission, by learning the prior trauma experiences and patient perspective on prolonged PED mental health stays. A convenience sample was collected at an urban hospital's PED among those boarding for mental health emergency greater than 24 hours. Demographic information, exposures to past trauma, and perceptions on and understanding of their care experience, were discussed. Descriptive and thematic content analysis were used for data analysis. A total of 99 youths were included in the study and the majority reported worsening mental health symptoms during PED boarding, notably increasing anxiety (72 [72.7%]). Patients were equivocal on efficacy of PED mental health intake on symptoms (41 [41.4%]). Personal suggestions were offered by these patients to guide the care of future children that would better mitigate their symptoms while boarding in the PED, such as group activities, electronics, and physical activity. Patients in mental health crisis boarding in the PED have already experienced stressful life events. By listening to the personal stories of this vulnerable population, the PED can improve care delivery and design a more therapeutic environment, especially as the need for acute mental health management continues to increase.

The development and validation of a novel deep-learning algorithm to predict in-hospital cardiac arrest in ED-ICU (emergency department-based intensive care units): a single center retrospective cohort study

Over recent years, the escalation of patient volumes in emergency departments (ED) worldwide has posed to the delivery of timely critical care. Intensive Care Unit (ICU) services became essential due to increasing acuity in EDs, and previous studies revealed a strong association between prolonged boarding times and unfavorable outcomes. Innovative strategies such as Emergency Department-based Intensive Care Units (ED-ICUs) have been introduced to optimize critical care delivery. Given the higher acuity and mortality rates in ED-ICU patients, the prediction of certain events, such as In-Hospital Cardiac Arrest (IHCA), has become abstruse. Conventional Early Warning Scores (EWSs) were developed to stratify the risk of conventional ICUs, but have never been validated in ED-ICU patients with higher acuity. Moreover, EWSs are predominantly focused on forecasting mortality and lack capability for real-time prediction. Our study aimed to develop and validate a deep-learning-based model to predict IHCA within 24 h in ED-ICU. We included 1975 patients admitted to ED-ICU. The study period was from 01 January 2019 to 31 December 2020. Our model, the Deep-ICU CMS (Central Monitoring System), uses four classic vital signs (blood pressure, heart rate, respiratory rate, and body temperature) as input. The model outperformed conventional EWSs in predicting IHCA and maintained performance even with extended prediction windows; it provided robust prediction within a 24-h window, setting it apart from models with restricted prediction horizons. It achieved notably high sensitivity and specificity, overcoming the alarm fatigue issue that is common in EWSs. This study pioneered IHCA risk stratification in ED-ICU and showcases Deep-ICU CMS as a robust prediction tool that overcomes the limitations of conventional EWSs. Prospective and external validation are now warranted to confirm the impact of Deep-ICU CMS in real-world practice. Given the scarcity of research in ED-ICU, our findings contribute valuable insights to optimizing critical care delivery.

Selection bias in estimating the relationship between prolonged ED boarding and mortality in emergency critical care patients.

ObjectivesStudies have found that prolonged boarding time for intensive care unit (ICU) patients in the emergency department (ED) is associated with higher in‐hospital mortality. However, these studies introduced selection bias by excluding patients with ICU admission orders who were downgraded and never arrived in the ICU. Consequently, they may overestimate mortality in prolonged ED boarders.MethodsThis was a retrospective cohort study at a single center covering the period from August 14, 2015 to August 13, 2019. Adult ED patients with medical ICU admission orders and at least 6 hours of subsequent critical care in either the ED or the ICU were included. Patients were classified as having either prolonged (>6 hours) or non‐prolonged (≤6 hours) ED boarding. Downgraded patients were identified, and mortality was compared, both including and excluding downgraded patients.ResultsOf 1862 patients, 612 (32.9%) had prolonged boarding; at 6 hours after ICU admission order entry, they were still in the ED. The remaining 1250 (67.1%) had non‐prolonged boarding; at 6 hours after the ICU admission order entry, they were already in the ICU. In‐hospital mortality in the non‐prolonged boarding group was 18.9%. In the prolonged boarding group, 296 (48.4%) patients were downgraded in the ED and never arrived in the ICU. Including these ED downgrades, the mortality in the prolonged boarding group was 13.4% (risk difference ‐5.5%, 95% confidence interval [CI] ‐8.9% to ‐2.0%, P = 0.0031). When we excluded downgrades, the mortality in the prolonged boarding group increased to 17.4% (risk difference ‐1.5%, 95% CI ‐6.2% to 3.2%, P = 0.5720). The lower mortality in the prolonged group was attributable to lower severity of illness (mean emergency critical care SOFA [eccSOFA] difference: ‐0.8, 95% CI ‐1.1 to ‐0.4, P < 0.0001).ConclusionsExcluding critical care patients who were downgraded in the ED leads to selection bias and overestimation of mortality among prolonged ED boarders.

Utility of Nonspecific Laboratory Testing for Psychiatric Patients Undergoing Medical Screening in a Military Emergency Department.

Psychiatric complaints account for a sizable and increasing portion of emergency department (ED) visits. Compared with other medical patients, these patients often require substantial resources because of limited specialized resources and prolonged boarding times, which can be detrimental to the safety and satisfaction of other patients. This can prompt early and indiscriminate laboratory testing to expedite early requests for admission consideration. Numerous emergency medicine literature and clinical policies already recommend against indiscriminate screening labs for these patients, yet many psychiatric services require these tests. This study further evidences the limited clinical utility and high associated costs of mandatory protocol screening labs for psychiatric patients evaluated in military EDs. A retrospective chart review of 441 active duty military patients and their families presenting to Madigan Army Medical Center's ED who received psychiatric diagnoses underwent analysis. A 3-physician review panel evaluated each identified patient case to confirm eligibility and determine whether or not laboratory studies led to a change in patient disposition that was not identified by history, review of systems, physical exam, and known past medical history. The review was approved by the hospital's institutional review board. Contemporary laboratory tests ordered in the evaluation of these patients included complete blood count with differential, complete metabolic panel, thyroid-stimulating hormone, serum ethanol, serum acetaminophen, serum salicylates, urine drug screening, urinalysis, urine human chorionic gonadotropin, and electrocardiograms. Broad screening labs may have altered dispositions for 0.9% (4) of patients. In total, 93% (202) of admitted patients were dispositioned to a psychiatric service. Of the 15 patients admitted to a medical service, 10 involved overdoses or intoxication. One patient had anemia in addition to opioid use disorder as diagnoses and was dispositioned to a medicine service. One pediatric patient was admitted for observation only. The remaining patients had diagnoses based on physical exam and history requiring medical service admission. In total, 7 patients had unknown dispositions, of which 4 carried solely psychiatric diagnoses. The cumulative reimbursement costs of broad testing in the studied population were estimated at $36,325.17 and rarely altered patient disposition. Further testing does not increase the incidence of disposition altering diagnoses and is associated with increased costs. When individual state laws and the clinical assessment by the responsible emergency physician are considered, future standardized ED lab screening evaluations of psychiatric patients in military EDs may be concentrated to breathalyzer alcohol level, urine drug screen, serum salicylates, serum acetaminophen, and urine human chorionic gonadotropin.

A Resident-Led QI Initiative to Improve Pediatric Emergency Department Boarding Times.

Pediatric emergency department (PED) overcrowding and prolonged boarding times (admission order to PED departure) decrease quality of care. Timely transfer of patients from the PED to inpatient units is a key driver that relieves overcrowding. In 2015, PED boarding time at our hospital was 10% longer than the national benchmark. We described a resident-led quality-improvement initiative to decrease PED mean boarding times by 10% (from 173 to 156 minutes) within 6 months among general pediatric admissions. We applied Plan-Do-Study-Act (PDSA) methodology. PDSA 1 (October 2016) interventions were bundled to include streamlined mobile communications, biweekly educational presentations, and reminder signs. PDSA 2 (August 2017) provided alternative workflows for senior residents. Outcomes were mean PED boarding times for general pediatrics admissions. The proportion of PICU transfers within 12 hours of admission served as a balancing measure. Statistical process control charts were used to analyze boarding times and PICU transfer rates. Leading up to PDSA 1, monthly mean boarding times decreased from 173 to 145 minutes and were sustained throughout the study period and up to 1 year after study completion. The X-bar chart demonstrated a shift with 57 consecutive months of mean boarding times below the preintervention mean. There were no changes in PICU transfer rates within 12 hours of admission. Resident-led quality improvement efforts, including education and streamlined workflow, significantly improved PED boarding time without causing harm to patients.

Emergency short-stay wards and boarding time in emergency departments: A propensity-score matching study

ObjectivesThis study aimed to validate the effectiveness of an emergency short-stay ward (ESSW) and its impact on clinical outcomes. MethodsThis retrospective observational study was performed at an urban tertiary hospital. An ESSW has been operating in this hospital since September 2017 to reduce emergency department (ED) boarding time and only targets patients indicated for admission to the general ward from the ED. Propensity-score matching was performed for comparison with the control group. The primary outcome was ED boarding time, and the secondary outcomes were subsequent intensive care unit (ICU) admission and 30-day in-hospital mortality. ResultsA total of 7461 patients were enrolled in the study; of them, 1523 patients (20.4%) were admitted to the ESSW. After propensity-score matching, there was no significant difference in the ED boarding time between the ESSW group and the control group (P = 0.237). Subsequent ICU admission was significantly less common in the ESSW group than in the control group (P < 0.001). However, the 30-day in-hospital mortality rate did not differ significantly between the two groups (P = 0.292). When the overall hospital bed occupancy ranged from 90% to 95%, the proportion of hospitalization was the highest in the ESSW group (29%). An interaction effect test using a general linear model confirmed that the ESSW served as an effect modifier with respect to bed occupancy and boarding time (P < 0.001). ConclusionAn ESSW can alleviate prolonged boarding time observed with hospital bed saturation. Moreover, the ESSW is associated with a low rate of subsequent ICU admission.

Association between adopting emergency department crowding interventions and emergency departments' core performance measures

ObjectivesTo estimate the association between adopting emergency department (ED) crowding interventions and emergency departments' core performance measures. MethodsWe analyzed the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2007 to 2015. The outcome variables are ED length of stay for discharged and admitted patients, boarding time, wait time and percentage of patients who left ED before being seen (LWBS). The independent variables are whether or not a hospital adopted each of the 20 crowding interventions. Controlling for patient-level, hospital level and temporal confounders we analyze and report results using multivariable logit model. ResultsBetween 2007 and 2015, NHAMCS collected data for 269,721 ED visit encounters, representing a nationwide of about 1.18 billion separate ED visits. Of 20 crowding interventions we tested, using adopting bedside registration (OR = 0.89, 95% CI = 0.75–0.98, P < .05), electronic dashboard (OR = 0.86, 95% CI = 0.76–0.98, P < .05), kiosk check-in technology (OR = 0.56, 95% CI = 0.41–0.83, P < .001), physician based triage (OR = 0.86, 95% CI = 0.73–0.99, P < .05) full capacity protocol (OR = 0.91, 95% CI = 0.79–0.99, P < .05) are associated with decrease in the odds of prolonged wait time. Adopting kiosk check-in (OR = 0.55, 95% CI = 0.35–0.85, P < .05) is associated with a decrease in the odds of prolonged boarding time. Using wireless communication devices (OR = 0.77, 95% CI = 0.57–0.97, P < .05), bedside registration (OR = 0.77, 95% CI = 0.64–0.094, P < .05) and pooled nursing (OR = 0.84, 95% CI = 0.72–0.98, P < .05) are associated with decrease in the odds of a patient LWBS. ConclusionsMajority of interventions did not significantly associated with ED' core performance measures.

Association of sudden in-hospital cardiac arrest with emergency department crowding

BackgroundIn Taiwan, emergency department (ED) crowding is inevitable; many studies have investigated the various negative effects of ER crowding on patients. In general, ED crowding reduces patient satisfaction, delays treatment, and increases mortality. However, most studies have focused on the relationship between ED crowding and delay mortality rather than sudden mortality. This study investigates the association of ED crowding with sudden unexpected in-hospital cardiac arrest (IHCA). MethodsThe retrospective observational study recruited patients with sudden IHCA in an ED from February 2016 to September 2017. Exclusion criteria included (1) out-of-hospital cardiac arrest, (2) patient with signed do-not-resuscitate consent, (3) pediatric patient, and (4) trauma patient. ED crowding parameters, including ED bed occupancy rates (EDBORs), number of boarding patients, and patients with boarding time to general ward or intensive care unit of >24 and >48 h, all were recorded every 2 h. ResultsSignificant increments were noted in IHCA incidence when EDBOR was >260%, with a rate ratio of 1.50 (95% confidence interval [CI], 1.03–2.17). However, the number of boarding patients was not associated with IHCA incidence (P > 0.05). Prolonged boarding time to general ward and ICU of >24 and >48 h both increased the IHCA incidence. ConclusionThis first study investigating the relationship between ED crowding and sudden IHCA found EDBORs and prolonged boarding to general wards or ICUs were associated with increased sudden IHCA incidence.

Are Seat and Aisle Interferences Affecting the Overall Airplane Boarding Time? An Agent-Based Approach

Seat and aisle interferences are assumed to be linked with a prolonged boarding time along with several other aspects related to airplane boarding such as: luggage handling, luggage distribution inside the cabin, number of passengers, passengers’ physique characteristics, group behavior, seat selection, aircraft occupancy, aircraft design, etc. Based on these assumptions, a series of proposed boarding methods, underlying their efficiency starting from the absence or limited presence of these types of interferences, are proposed. The present paper aims to analyze whether the different types of seat or aisle interferences do matter for the overall boarding time by considering 24 boarding methods proposed in the literature. A series of specific elements related to interferences, such as: the average waiting time, the average number of interferences based on their types, and the average number of interference-affected passengers, have been considered. Also, the presence of multiple interferences in different parts of the aircraft has been analyzed in order to offer a complete picture of the considered situation. An agent-based model in NetLogo 6.0.4, fed with values form field trials within the literature is created and used for simulations, which enables the agents to act like real passengers involved in an airplane boarding process.

MP12: Emergency department boarding: predictors and outcomes

Introduction: Delays in transfer to an in-patient bed of admitted patients boarded in the ED has been identified as one of the chief drivers of ED overcrowding. Our study aims to replicate findings from a previous study in identifying patient characteristics associated with increased boarding time, and the impact of increased boarding time on in-patient length of stay (IPLOS). Methods: We conducted a retrospective single-centre observational study during the period between January 1, 2015 December 31, 2015 at a very high volume community hospital (~ 75,000 ED visits/year). All patients admitted from the ED to Medicine, Pediatrics, Surgery, and Critical Care were identified. The mean time to in-patient bed (TTB), as well as patient-specific and institutional factors that were associated with prolonged boarding times ( 12 hours) were identified. Mean IP LOS was calculated for those with prolonged boarding times and compared to those without prolonged boarding times. Results: There were 8,096 unique admissions during the study period. Patients admitted to the Medicine service exhibited significantly higher boarding times than those admitted to other services, with a mean boarding time of 17.4 hrs, as compared to 4.2 hrs, 5.7 hrs, and 4.0 hrs for those admitted to Surgery, Critical Care and Pediatrics respectively. Within Medicine patients, there was a statistically significant greater odds of prolonged boarding time for patients who were older, had a greater comorbidity burden, and required more specialized in-patient care (i.e. an isolation bed or telemetry bed). Medicine patients with prolonged boarding times also experienced 0.7 days longer IP LOS, even after correcting for age and comorbidity (mean adjusted IP LOS 10.6 days versus 11.3 days). Conclusion: Within our study period, older, sicker patients and those patients requiring more resource-intensive in-patient care have the longest ED boarding times. These prolonged ‘boarding’ times are associated with significantly increased IP LOS.

Emergency department boarding: a descriptive analysis and measurement of impact on outcomes.

Delays in transfer of admitted patients boarded in the emergency department (ED) to an inpatient bed is a major driver of ED overcrowding. We sought to identify explanatory factors behind ED boarding as well as the impact of boarding on total inpatient length of stay (IP LOS) and inpatient mortality. We conducted a retrospective single-centre observational study during the period between January 1 and December 31, 2015 at a very high volume community hospital. All patients admitted from the ED to Medicine, Pediatrics, Surgery, and Critical Care were identified. The mean ED LOS and boarding time as well as patient-specific and institutional factors that were independently associated with prolonged ED LOS (≥24 hours) and prolonged boarding time (≥12 hours) were identified. Mean inpatient length of stay (IP LOS) and the odds of inpatient mortality were calculated for those patients with prolonged ED wait times. There were 13,872 unique admissions during the study period. Patients admitted to the Medicine service exhibited significantly higher ED wait times than other services. Within Medicine patients, there was a statistically significant greater odds of prolonged ED wait times for patients who were older, had a greater comorbidity burden, and required more specialized inpatient care. Medicine patients with prolonged boarding times also experienced a mean of 0.9 days longer IP LOS even after adjusting for confounders. Within our cohort, older, sicker patients and those patients requiring more resource-intensive inpatient care had the longest ED wait times. These prolonged wait times are associated with significantly increased IP LOS.

Analysis of Emergency Department Length of Stay for Mental Health Patients at Ten Massachusetts Emergency Departments

Prolonged boarding times in the emergency department (ED) disproportionately affect mental health patients, resulting in patient and provider dissatisfaction and increased patient morbidity and mortality. Our objective is to quantify the burden of mental health boarding and to elucidate the effect of insurance together with demographic, social, and comorbid factors on length of stay. We conducted a cross-sectional observational study of 871 consecutive patients requiring an ED mental health evaluation at one of 10 unaffiliated Massachusetts hospitals. Demographics; insurance; length of stay; medical, psychiatric, and social history; and disposition data were collected. We evaluated the effect of these characteristics on boarding time. ED median length of stay varied greatly by disposition, driven primarily by ED boarding time. Admitted and transferred patients had longer delays than discharged patients (5.63, 9.32, and 1.23 hours, respectively). Medical clearance time (1.40 hours) composed only 10.5% of total ED length of stay and varied little by insurance. In our multivariate analyses, patients with Medicaid and the uninsured had significantly longer total lengths of stay and were more than twice as likely to remain in the ED for 24 hours or greater compared with privately insured patients. Mental health patients in Massachusetts have lengthy ED visits, particularly those requiring inpatient admission. Boarding time accounts for the majority of total ED length of stay and varies by insurance, even when other factors known to affect ED length of stay are controlled. Efforts to improve timeliness of care for mental health emergencies should focus on reducing ED boarding and eliminating disparities in care by insurance status.

The Effect of Emergency Department Crowding on Patient Satisfaction for Admitted Patients

The objective was to study the association between factors related to emergency department (ED) crowding and patient satisfaction. The authors performed a retrospective cohort study of all patients admitted through the ED who completed Press-Ganey patient satisfaction surveys over a 2-year period at a single academic center. Ordinal and binary logistic regression was used to study the association between validated ED crowding factors (such as hallway placement, waiting times, and boarding times) and patient satisfaction with both ED care and assessment of satisfaction with the overall hospitalization. A total of 1,501 hospitalizations for 1,469 patients were studied. ED hallway use was broadly predictive of a lower likelihood of recommending the ED to others, lower overall ED satisfaction, and lower overall satisfaction with the hospitalization (p < 0.05). Prolonged ED boarding times and prolonged treatment times were also predictive of lower ED satisfaction and lower satisfaction with the overall hospitalization (p < 0.05). Measures of ED crowding and ED waiting times predicted ED satisfaction (p < 0.05), but were not predictive of satisfaction with the overall hospitalization. A poor ED service experience as measured by ED hallway use and prolonged boarding time after admission are adversely associated with ED satisfaction and predict lower satisfaction with the entire hospitalization. Efforts to decrease ED boarding and crowding might improve patient satisfaction.