'Boarding' Admitted Patients in the ER Associated with Higher Rates of Patients Leaving Without Treatment

For more information and interviews with Dr. Schneider, contact Brian Ruberry,
301-948-1709, [email protected].
Las Vegas, Sept. 30—When emergency patients who are “boarded,” or held in the emergency department after admission to the hospital, reaches a certain threshold, the rate of other patients leaving without medical treatment increases “significantly,” according to research being presented at the annual meeting of the American College of Emergency Physicians. Additional research shows that when hospital leadership creates and enforces policies to more rapidly move admitted patients out of the emergency department, the wait for an in-patient bed drops by more than 50 percent.
Other research  presented shows that accountability to hospital governing boards can reduce boarding times, and with them waiting times, particularly for cardiac patients.
“Boarding harms patients and ACEP is committed to ending this dangerous practice,” said Sandra Schneider, MD, FACEP, president of the American College of Emergency Physicians.  “The research shows that crowding in emergency departments cannot be resolved in the emergency department alone.  Hospital leaders must be involved to ensure that these patients, often the sickest in the hospital, get the attention and expertise they deserve.  As health care reform is implemented and emergency patient visits continue to rise, it is more urgent than ever that we exert pressure on hospitals and policymakers to end the practice of boarding.”
Dr. Schneider also said emergency departments use a triage process to ensure the most critically ill patients are treated first, but some very sick patients do not initially have the symptoms of a medical emergency.  If the gridlock in emergency departments could be reduced by increasing throughput, patients would not leave without being seen, which can dangerous, especially when millions more people are seeking emergency care every year, and visits are expected to increase, despite health care reform.
Emergency visits in the U.S. increased to nearly 124 million in 2008, up from nearly 117 million in 2007, according to a new report from the Centers for Disease Control and Prevention. http://bit.ly/ak6oRx 
Researchers in Florida developed a model to calculate the point at which patients in the waiting room began to leave without receiving treatment.  When boarding hours reached 8.5 percent of all available emergency department bed hours, patients in the waiting room were significantly more likely to leave.
“High rates of patients leaving without being treated are poor for patient safety,” said lead study author Jason Wilson, MD, of the University of South Florida in Tampa, Fla.  “Our study affirms that long waiting room times correlate with larger numbers of patients leaving prior to physician evaluation.  And we know that long waiting times are directly connected to boarding in most hospitals.”
Additional research showed that hospital policies can have significant effects on wait times.   For example, a hospital that enforced a policy to make inpatient beds ready within 30 minutes for patients admitted from the emergency department to internal medicine or general surgery showed dramatic improvement in overall length of stay for those patients.
“When our hospital implemented a policy of moving admitted patients out of the ER and into in-patient beds within 30 minutes, overall time from bed assignment to transfer to the appropriate floor dropped by more than half,” said study author Daniel Pauze, MD, of Albany Medical College in Albany, NY.  “It shows that we can get patients out of the ER and into inpatient beds if hospital leadership demands it.  It’s good for both patient safety and the hospital’s bottom line when you stop people walking out the door without treatment.” 
Another study showed that the interval between arrival at the emergency department and administration of angioplasty for heart attack patients was “significantly better” at hospitals where the frequency of  emergency department boarding is reported to hospital governing boards.  This is important in view of a study published in 2008 by Health Affairs showing that wait times for heart attack patients increased from by 150 percent from 1997 to 2004, and that a quarter of heart attack patients waited 50 minutes or more before seeing a doctor, a potentially dangerous delay in care.
“Reducing emergency department wait times and ‘boarding’ can only be solved by a concerted effort at multiple hospital levels and transparency about how long patients are actually being boarded,” said Dr. Schneider.  “ACEP has advocated for years for everyone in health care, not just emergency physicians, to work together to end the practice of boarding.  This research is important to this effort, because it shows that collaboration is effective. Emergency department crowding is an institutional problem that requires institutional solutions.”
ACEP is a national medical specialty society representing emergency medicine. ACEP is committed to advancing emergency care through continuing education, research and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies. 
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