January 7, 2020 Advisory Board's take: What's missing from the ED boarding debate

It's not uncommon for U.S. patients to wait in the ED for several hours for an inpatient bed to become available, but the practice, known as "boarding," can hinder patient care, Clayton Dalton and Daniel Tonellato, resident physicians at Massachusetts General Hospital (MGH) and Brigham & Women's Hospital, write in an opinion piece for NPR's "Shots."

What is boarding?

When an ED patient is admitted to the hospital as an inpatient, they often spend several hours waiting for their hospital bed to become available. The practice, which Dalton and Tonellato describe as a "stubborn problem," is called boarding.

CDC data shows that most U.S. hospitals board patients in the ED for more than two hours at a time. According to a 2016 CDC report, the practice has become more common in recent years, with about 66% of hospitals in 2016 reporting boarding patients for more than two hours, compared with 57% in 2009.

But while the practice is increasingly common, health experts say it has an adverse effect on emergency care.

"Waiting hours for a hospital bed can be maddening for patients and their families," Dalton and Tonellato write. "Sometimes literally." They cite a study that found an association between patients who had long waits in ED and delirium.

Boarding is also one of the biggest factors of overcrowding, according to the American College of Emergency Physicians. "And overcrowding, in turn, has been associated with everything from delays in administration of pain medication and antibiotics to longer inpatient stays, greater exposure to medical error, delayed treatment for heart attack and even increased mortality," Dalton and Tonellato write.

Why do EDs board their patients?

If boarding has adverse effects, why do hospitals continue to board patients?

According to Dalton and Tonellato, "The answer … is complicated. But it has a lot to do with money."

They explain that while the issue may appear to be a "basic supply and demand problem," with more hospitals closing as annual ED visits rise, there's one "curveball." Most hospitals operate at an average 65% of their total inpatient capacity, meaning they aren't full like the ED.

However, because of the way Medicare reimbursement rates are structured and surgical schedules are arranged, there is "wide variation in the number of postoperative patients needing admission to the hospital on any given day," Dalton and Tonellato write. 

For example, they note that hospitals often prioritize invasive procedures, which are reimbursed at higher rates, and allow the specialists performing the procedures to establish their own schedules. "As a result, dozens of surgeries might be scheduled for a Monday morning, just a handful the following day and almost none over the weekend," Dalton and Tonellato write. They explain that any surge in "post-op patients needing hospital beds means fewer beds for [ED] patients, which creates a bottleneck and leads to boarding."

"The variation in demand causes hospitals to swing between overcrowding and underutilization," Dalton and Tonellato write.

Other sources of boarding include poor staffing on nights and weekends, bad discharge planning, and reserving certain hospital beds for certain specialties, according to Dalton and Tonellato.

How to address the issue

But the good news is improving efficiency is more cost efficient than increasing a hospital's capacity, the authors write. 

Cincinnati Children's Hospital, for instance, increased occupancy from 76% to 91%, made an additional $137 million in revenue and avoided a $100 million hospital expansion by streamlining their discharges and adjusting their surgical schedule, Dalton and Tonellato write.

Other hospitals, including MGH and Brigham & Women's, are using similar methods to address the issue, but while Medicare has started offering financial incentives to hospitals that address boarding, it may not be enough, the authors note.

Overall, Dalton and Tonellato argue a more overarching change is needed. "Ultimately, we suspect that what is really needed is an overhaul of the current system of financial incentives and reimbursement, coupled with penalties for hospitals that fail to act on the problem," they write (Dalton/Tonellato, "Shots," NPR, 11/30/19).

Advisory Board's take

What's missing from the ED boarding debate

Megan Tooley, Practice Manager, Cardiovascular Roundtable

This opinion piece highlights the challenges of misaligned incentives in health care leading to poor patient care. However, while the authors explore one aspect of the problem—patients admitted from the ED without an inpatient bed available—they don't address another driving factor: patients who didn't actually need to be admitted, and perhaps shouldn’t have come to the ED at all.

This is unfortunately a widespread challenge. In fact, one recent report from Premier suggests about a third of ED visits from chronically ill patients were unnecessary, or could be treated in an outpatient setting. And once a patient arrives at the ED with a complex condition, it can be challenging for emergency department physicians to appropriately treat or manage them efficiently, sometimes leading to unnecessary admission for additional testing or consults.

We see this frequently in the cardiovascular space, particularly patients presenting in the ED with chest pain. If emergency physicians can't get a specialist consult quickly enough, or don’t have criteria in place to help identify if a patient really needs to be admitted or can be managed in observation and then discharged, it can result in an unnecessary admission. Thus, contributing to the capacity challenges the authors mentioned.

However, we have found some programs have been able to reduce unnecessary utilization and admission by implementing protocols and education to risk stratify and triage ED patients presenting with certain conditions like chest pain. For example, MemorialCare Long Beach Medical Center in California saw ED and observation length of stays declines after it implemented the HEART score for chest pain in the ED to better identify and treat low-risk patients.

Of course, the issue the authors raise of misaligned incentives leading to boarding is very real, and needs to be addressed. But in the interim, there are steps that EDs can take to alleviate this problem that will benefit both patients and hospitals. To get those steps, as well as the tool that MemorialCare used, download our research on improving CV patient management in the ED and observation.

Download the Report