Dr. Erkan Hassan

Monthly Writings

Evaluations and reviews of the latest in the field.

Solutions to Emergency Department Overcrowding and Boarding

The ED Crisis

SUMMARY:

  • Emergency Department (ED) overcrowding and boarding is associated with poor clinical outcomes and increased costs.

  • Various interventions can address patient flow.

  • Virtual emergency services have been proposed as an alternative care model.

REVIEW

STATISTICS

  • 2021 Total U.S. ED visits: 139,781,000

  • Time Spent in ED:

    • 1 – 10 hours: 81.3% of patients

    • 2 - 10 hours: 63.8% of patients

  • ED to Hospital Admission: 18.3 million (13.1%)

  • ED to ICU or Step-Down: 3.35 million (2.4%)

  • ED admit to observation unit: 3.28 million (2.3%)

  • Left Without Being Seen (LWBS): 2.33 million (1.7%)

  • 2023 California Hospital Association

  • 7 million unnecessary ED hours annually

  • Cost of $3.25 billion

DEFINITIONS:

ED Overcrowding:

  • No clear definition

  • Position Statement:

  • “the situation in which ED function is impeded primarily because of patients waiting to be seen, undergoing assessment and treatment, or waiting for departure comparing to the physical or staffing capacity of the ED.”

ED Boarding:

  • No clearly accepted definition

  • Joint Commission statement:

  • “ the practice of holding patients in the ED or another temporary location after the decision to admit or transfer has been made.  It is recommended that boarding time frames do not exceed 4 hours in the interest of patient safety and quality of care.”

Outcomes:

Clinical Outcomes

Other Outcomes:

  • Patients leaving without being seen: Loss of $1,000 - $2,000 per patient

  • Medical errors & Treatment side effects

  • Patient dissatisfaction

  • Reduced hospital capacity

  • Ambulance diversions

  • Increased workload

  • Staff frustration

  • Longer wait times

ROOT CAUSE

  • Increased ED volume

  • Impaired Upstream Disposition

    • Inpatient beds (ICU & Floor)

    • Recovery Beds (nursing home, rehab, long term care facilities)

    • Behavioral health

SOLUTIONS

3 types of patients:

Those unlikely to need ED (approximately 25%)

  • Those needing further evaluation of optimal care needs

  • Those in high need for in-person ED care

  • Timing of Solution

    • Pre-ED

    • Within ED

    • Post ED

CONCLUSIONS:

  • Emergency department overcrowding and boarding has become a commonplace occurrence and is associated with worse clinical outcomes.

  • Innovative strategies leveraging technology, virtual care and improved processes (triage and operational) can help improve the provision of ED care.

  • In order to obtain optimal outcomes, it is essential to address all 3 phases of patient flow: pre-ED, within-ED and post-ED.

Erkan Hassan