EMTALA and Patient Transfers

Written by: Mike Tandlich, MD (NUEM ‘24) Edited by: David Feiger, MD (NUEM ‘22)
Expert Commentary by: Michael Schmidt, MD

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Expert Commentary

While EMTALA was first enacted to address issues with “patient dumping”, it has had broad influence on how patients are treated, dispositioned, and transferred in emergency department and hospital settings. In addition, EMTALA law has taken on almost mythic proportions among healthcare workers and administrators, likely due to high-profile cases, the fear of potential violation of the law and subsequent penalties, the potential for it to bolster civil malpractice claims, misunderstanding of it by healthcare personnel, and variability in interpretation by regulatory bodies.

Emergency physicians are often called upon to make decisions as the default expert in EMTALA for patients presenting for emergency care or in fielding hospital transfer calls. Unfortunately, on-call specialty physicians involved in the acceptance of transfers, and even hospital transfer centers, may not have a good understanding of the statue. As such, emergency physicians who are not versed in EMTALA can put both the hospital and themselves at risk.

The infographic by Dr. Tandlich gives an excellent summary of EMTALA. In addition, it is imperative that hospitals and emergency departments establish clear processes and appropriate documentation for EMTALA-related situations. More specifically, important concepts to consider include:

• When conducting a medical screening exam (MSE), approach it as a process with consistent implementation for all patients and understand this often includes more than just a physical exam

• When accepting transfers from outside hospitals, do not solely rely on on-call physicians to make the decisions

• When transferring patients to outside hospitals, make clear the reasoning, the patient status, and the risks and benefits

It behooves emergency physicians, emergency department staff, and transfer centers to understand the basic concepts around EMTALA. Overall, the best advice is to do that which is in the best interest of the patient, as this will usually lead to the right decision.

Michael Schmidt, MD

Chief of Staff

Department of Emergency Medicine

Northwestern Memorial Hospital

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Tandlich, M. Feiger, D. (2022, Oct 31). EMTALA. [NUEM Blog. Expert Commentary by Schmidt, M]. Retrieved from http://www.nuemblog.com/blog/emtala-transfers

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Proper Preparation for Mass Casualty Incidents

Written by: August Grace, MD (NUEM ‘24) Edited by: Andrew Rogers, MD, MBA (NUEM ‘22)
Expert Commentary by: Andra Farcas, MD (NUEM ‘21)

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Introduction

In the setting of trauma, most hospitals are adept at treating and managing patients with a variety of injuries. However, the ability of a hospital to handle a mass casualty incident (MCI) requires a completely different approach and, most importantly, adequate triage and pre-planning. An MCI is defined as “an event that overwhelms the local healthcare system, where the number of casualties vastly exceeds the local resources and capabilities in a short period of time [7].” MCI events can include anything from hurricanes, earthquakes, and other natural disasters to terrorism or other man-made situations that include the use of explosive or biological weapons, mass shootings, or dysfunction in modes of transportation (car, plane, train crash) [3]. Although this is just a short list of the possibilities, each hospital must prioritize its response preparedness to match the likelihood of events that it could receive. For example, as a major urban center, Chicago is more likely to encounter events such as mass shootings, biological terrorism, or explosive injuries. Mobile, Alabama, on the other hand, must have adequate preparation for hurricanes and floods [4]. This post will discuss a brief overview of hospital planning and operational setup with key elements of a disaster response from events that cause high numbers of blunt trauma, penetrating trauma, burns or crush injuries that may be seen following explosive events, mass shootings, or large scale motor vehicle collisions, to name a few. 

Casualty Planning & Staffing Considerations

Arguably the most important step in an MCI is the planning that occurs before a single patient is even seen. In most events, hospitals have communication with EMS personnel that are on scene allowing them to have some sort of estimation of the scale of the event and type of disaster encountered. If the mechanism and scale are appropriate, a properly planned disaster response should be initiated and set in motion a sequence of coordinated events. 

In creating a disaster response plan, the first step is the designation of the Disaster Medical Officer (DMO). This person should be the most senior ED attending physician and he/she oversees available hospital medical personnel and resources [1]. This person will have no role in patient care and instead will be in charge of all ED operations, delegating tasks, and problem solving issues that arise in the future. 

The first task of the DMO is to get help and get it now. Approximately half of all casualties will arrive at the hospital within a one hour window, with 50-80% arriving within 90 minutes. Time begins after the first patient arrives at the hospital [8]. Therefore, getting the appropriate staff to the hospital as quickly as possible is vital to saving lives. How much staff is needed? This can be gauged by the type of disaster encountered and with assistance from EMS personnel at the scene. A five-car motor vehicle collision (MVC) will not require as much additional staff as a collapsed high rise building. The DMO will delegate the task of calling available staff to maximize the number of staff present in the ED and hospital. Contacting surgeons, scrub techs, anesthesiologists, and nurses to get as many ORs operational is invaluable to saving lives. 

Continuous staffing adjustments can be monitored and made by using the casualty predictor tool (Figure 2). When in doubt, it is better to have more staff available than needed. To reiterate, the most important part of any disaster situation is to GET HELP.

Triage/ED Setup

Once the process is underway for increasing the level of resources available, the next step is hospital setup and triage. The most important part of this step is creating enough space to allow for the massive influx of patients and maintaining proper flow throughout the ED. It is well known that most hospitals in large population centers already operate at or near full capacity [4]. This makes it even more challenging when presented with an acute influx of patients in a short period of time. There is not much that can be done in the acute setting about patients that are already admitted; however, the ED can be restructured to account for the increased surge. Patients currently in the ED with a condition deemed to be stable (will likely not require an acute intervention in the next 24 hours) can be moved to a different area (green triage area, discussed below). The patients who have a more acute condition can be triaged and recategorized using the same criteria as the incoming casualties. 

One current method of triaging patients is the tagging method. In this system, patients are tagged with a red, yellow, or green identification that categorizes patients based on acuity. Other things listed on tags can be a patient’s name, bar code, MRN or other tracking criteria. These patients are then able to be treated based on the level of care needed. In theory, this is a good way for patients to be tracked and accounted for. However, some experts believe that when there is a large volume of patients, this can slow the triage process and extend the amount of time it takes the patient to receive care that may be lifesaving. Another limitation is that it does not allow for a dynamic system, it provides a false sense of security, and can cause confusion. For example, a patient may have a green tag when initially triaged but could decompensate to a yellow or red tag [6]. Thus, there should be an appropriate system for re-evaluation if resources allow. 

One system that could be used instead is a tag zone. In this system, the ED could be set up into different zones that would correlate with the tag color and acuity of the condition. Who should triage? The second most senior ED attending physician. The zone system could be set up as follows: 

Red zone: Patients that need immediate medical or surgical attention. This includes patients presenting with an acute airway, circulatory or neurologic problem, multi-system involvement, or penetrating injuries to the head, neck, or chest. These patients are likely to need the vast majority of resources and staff. 

Orange zone: Not originally categorized in the tag system. These patients are expected to decompensate within the hour but did not need immediate resuscitation [2]. 

Yellow zone: Patients that are relatively stable that will likely not decompensate within the hour. Extremity injuries or conditions that have time to be worked up. 

Green zone: Patients with minor injuries that are unlikely to decompensate. “Walking wounded.” Will not require vast amounts of resources or staffing to be cared for. 

The different zones allow for a dynamic system. Patients in each zone will be cared for by a team of physicians and nurses with the majority of staffing located in Red and Orange zones. Patients can be moved “up” a zone (from yellow to orange) if their condition deteriorates or could be moved “down” a zone (from yellow to green) if they are able to be stabilized [1, 2, 3]. The “black tag” patients were not categorized into a zone as they were patients who were either already dead, or not likely to survive given the current staffing and resources available. Figure 3 shows a brief triaging algorithm (without the orange designation). This is one possible system to triage patients and get them to an appropriate level of care rapidly. The hospital system is now ready for the rapid influx of critical patients.

Implementation

All patients should enter through a single triage area. Multiple points of entry can cause confusion and overwhelm each area by not knowing the number of patients entering from each point [4]. As the number of patients in each zone starts to fill up, adequate communication about the space and number of resources available should be communicated to the DMO and charge nurse. Once patients are able to be stabilized in each zone, the goal is to get them to the OR for immediate surgery if needed, or to move them down a zone (yellow to green) in order to make space for additional critically injured patients.  

Who are the first patients to arrive? The “dual wave phenomenon” explains how patients usually present to the hospital following MCIs. The first wave of casualties are described as the “walking wounded” or those who are able to self-ambulate and usually only require minor care. These patients begin to arrive within 15-30 minutes of the incident depending on the distance from the scene to the hospital. It is important that these patients do not take up too many hospital resources or staff as they are likely well enough to survive with minimal therapeutic interventions. These patients can easily overwhelm the system and prevent proper care to more critical patients. The second wave includes the patients that arrive via EMS or other assistance from bystanders as they are not well enough to transport themselves. These are the patients who will require a vast majority of hospital staffing, resources, and time in order to prevent deaths [3, 4]. 

Summary

• The first step to preparing for an MCI is having a plan in place.

• GET HELP. If you only have time to do one thing it should be this. It does not matter how many resources you have or how much space is available if you do not have enough staff to use them.

• Have a triage plan. Create zones of various acuity with the majority of staff occupying the higher acuity areas. Patients can always be moved to a higher zone if they need more care or a lower zone if they have been stabilized. 

• Get patients to the proper provider. If the patient needs surgery, get them to the OR. This also creates space for new patients to be seen.

• Have one single area of entry. This allows the system to maintain consistency and flow. 

References

1. Emergency Safety Officer Management Plan For Mass Casualty. Kings County Hospital Center, www.downstate.edu/emergency_medicine/pdf/KCHCSection03.pdf. 

2. Menes, Kevin. “How One Las Vegas ED Saved Hundreds of Lives After the Worst Mass Shooting in U.S. History: Emergency Physicians Monthly.” EPM, 5 Apr. 2020, epmonthly.com/article/not-heroes-wear-capes-one-las-vegas-ed-saved-hundreds-lives-worst-mass-shooting-u-s-history/. 

3. Hospital Medical Surge Planning for Mass Casualty Incidents. Florida Department of Health, www.urmc.rochester.edu/MediaLibraries/URMCMedia/flrtc/documents/WNY-Hospital-Medical-Surge-Planning-For-Mass-Casualty-Incidents.pdf. 

4. Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. https://doi.org/10.17226/11621

5. “SALT Mass Casualty Triage Algorithm - CHEMM.” U.S. National Library of Medicine, National Institutes of Health, chemm.nlm.nih.gov/salttriage.htm. 

6. “Report: Mass Casualty Trauma Triage Paradigms and Pitfalls .” Journal of Emergency Medical Services , Office of the United States Assistant Secretary for Preparedness and Disaster Response. 

7. DeNolf, Renee L. “EMS Mass Casualty Management.” StatPearls [Internet]., U.S. National Library of Medicine, 15 Oct. 2020, www.ncbi.nlm.nih.gov/books/NBK482373/. 

8. “Mass Casualty Predictor .” Homeland Security Digital Library , Centers for Disease Control and Prevention . 

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Expert Commentary

This is a great review of MCI management in the Emergency Department by Drs. Grace and Rogers. Although the past few years of the COVID-19 pandemic have felt like we’ve been working in a perpetual MCI, these are important principles to review on a regular basis, as they are not something we necessarily practice every day in the emergency department.

The authors do a good job of emphasizing the importance of preparing for an MCI ahead of time. Another important aspect of preparation is decontamination. An ED disaster response plan should incorporate how to effectively put patients (both walk-ins and EMS arrivals) through decontamination if the disaster at hand requires it. The authors emphasize the importance of having patients enter through a single triage area, and the decontamination station should be similarly set up nearby allowing for one-directional flow of patients through the decontamination process. This is not only vital to patient treatment but also to ensuring staff safety. Additionally, it is necessary to ensure that the ED has sufficient and adequate level Personal Protective Equipment and that the appropriate staff are trained on donning/doffing procedures. 

In addition to gathering the staffing resources, there should also be an emphasis on gathering disaster-specific supplies: alerting the blood bank if it is a traumatic MCI, amassing antidotes if it is toxicological in nature, compiling medical equipment (such as ventilators) as applicable, etc. Additionally, alerting other EDs in the system as to the impending influx of patients as well as reaching out to disaster-specific specialty centers (ie, hyperbarics facility for a structure fire for carbon monoxide treatment) can also help take pressure off and allocate more resources. 

Finally, the importance of a hotwash or after-action review cannot be emphasized enough. This is a process by which participants can have an open and honest professional discussion about what went well and what can be improved in the future. It centers around four main questions (What was supposed to happen? What did happen? What caused the difference? What can we learn from this?) and is vital for building an ED’s capacity for conducting an adequate emergency response to an MCI. 

References

1. Blackwell, T.H., DeAtley, C., Yee, A. (2021). Medical support for hazardous materials response. Cone, D.C. (ed). Emergency Medical Services Clinical Practice and Systems Oversight; Volume 2: Medical Oversight of EMS. (3rd edition, p339-351). UK: John Wiley and Sons, Ltd. 

2. Greenberg, T., Adini, B., Eden, F., Chen, T., Ankri, T., Aharonson-Daniel, L. An after-action review tool for EDs: learning from mass casualty incidents. Am J Emerg Med. May 2013;31(5):798-802. Doi 10.1016/j.ajem.2013.01.025. Epub 2013 Mar 6. PMID: 23481154.

3. Metz, T. How to Facilitate an After-Action Review (AAR or Hot Wash): Agenda and Tips. MG Rush Facilitation Training & Meeting Design. https://mgrush.com/blog/after-action-review/. 

4. Salem-Schatz, S., Ordin, D., Mittman, B. Guide to the after action review. Center for Evidence-Based Management. Oct 2010.  https://www.cebma.org/wp-content/uploads/Guide-to-the-after_action_review.pdf.

Andra Farcas, MD

Emergency Medicine & EMS Physician

CU Department of Emergency Medicine

University of Colorado School of Medicine

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Grace, A. Rogers, A. (2021, Apr 26). Proper Preparation for Mass Casualty Incidents. [NUEM Blog. Expert Commentary by Farcas, A]. Retrieved from http://www.nuemblog.com/blog/mass-casualty-incident-preparation

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ED Clinical Decision Making Units

Written by: Mitchell Blenden, MD (NUEM ‘24) Edited by: Em Wessling (NUEM ‘22) Expert Commentary by: Tim Loftus, MD, MBA

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Expert Commentary

Thank you to Dr’s Blenden and Wessling for the excellent overview of ED CDUs including some background and indications for their use. 

 Several points to highlight and elaborate upon include the following:

The background of the utility of CDUs mostly stems from their early function as rapid diagnostic and treatment centers (RDTCs) for chest pain.  The function and utility of CDUs have since grown to demonstrate clinical benefits well-established across a variety of conditions as Dr’s Blenden and Wessling have mentioned, including not only chest pain (rule out acute coronary syndrome) but also TIA, CHF, asthma, COPD, cellulitis, pyelonephritis, pneumonia, etc. 

Value and Benefits

The utility and value of ED CDUs will continue to expand.  The percentage of all hospital admissions that start in the ED continues to grow -- 67% in 2019, up from 58% in 2004 according to the ED Benchmarking Alliance.  Additionally, EDs cared for approximately 158M people as of 2018 (EMNet/NEDI-USA), up 32% over a 10 year period.  As the number of admissions continues to grow, and considering that some of these inpatient stays are short, it follows that many of these short inpatient admissions are subject to recovery audit contractors and payor denials.  Many clinical conditions which are often subject to short inpatient stays can be cared for in dedicated short stay observation units without adversely affecting, and for the most part improving, the quality of care delivery, safety, satisfaction, cost savings, and reducing subsequent inpatient LOS.  

All stakeholders in the health care system benefit from CDU use: patients are more accurately diagnosed before leaving the ED and are discharged home faster, payors avoid costly inpatient admission charges, hospitals keep scarce inpatient bed capacity open for more appropriate patients and avoid audits and denials, and providers deliver care in a setting that more appropriately matches patient needs to resources.

Dedicated Units with Protocolized Care

Observation patients can be managed in a variety of settings and contexts, but best practice that leads to best outcomes would be in dedicated observation units adherent to protocols tailored to the patients’ conditions, the best available evidence, and local institutional resources.

Shorter hospitalizations are more likely to occur in dedicated observation units under protocols than with unstructured hospitalization on inpatient teams and simply billing status changes to observation.

Financial Considerations

Much of the existing evidence has demonstrated that CDUs can provide care that efficiently utilizes resources and results in shorter hospital lengths of stay relative to other projects to expand capacity.   Further, hospitals may realize decreased operating expenses for those patients subsequently discharged home from the CDU who have diagnoses or clinical conditions that are not as profitable for the hospital to manage in the inpatient setting - for example, CHF, which can often create a loss for the hospital.  That being said, hospitals should be careful about shifting too much acute care into CDUs, because any CDU stay that subsequently results in inpatient admission (about 20% or so) are only paid by a single DRG, which includes that care provided for in the ED, CDU, and hospital unit. Thus, you can risk incurring additional costs without additional revenue. Finally, the duration of observation should exceed 8 hours only to justify the added expense of operating the CDU, because payors, including Medicare, generally do not pay clinical or facility fees for observation stays less than 8 hours.

Another consideration when estimating value created by a CDU is the increasing use by those who would have otherwise been discharged from the ED.  It is important to consider the value of a CDU not only by the cost savings to the hospital and patient but also the possible supply-induced demand of health care services and overutilization of those services to a detriment.

CMS, and other payors, do not necessarily exclude payment from observation status patients whose stay lasted longer than 24 or even 48 hours. However, the profit margin and efficiency are reduced when patients are staying in the CDU that long, highlighting an opportunity to evaluate your particular unit’s effectiveness, efficiency, and patient selection.

Final Considerations

CDUs are not appropriate for all EDs, as only about 5-10% of ED patients have been found to be appropriate for a CDU, and in order to optimize operational and financial efficiency, a certain minimum number of beds and fixed costs would need to be overcome. 

It is worth mentioning that protocol-driven CDUs in proximity to an ED with dedicated diagnostic and treatment algorithms, patient selection criteria, predetermined outcomes and end points have demonstrated the best outcomes with respect to cost savings, patient satisfaction, safety, and reduction in hospital LOS.  For administrative and clinical operations leaders, tracking process and outcome metrics such as LOS, occupancy rate, discharge rate, and bed turns in addition to other clinical and quality outcomes will enable ongoing continuous optimization of the CDU.

Depending on the resources and throughout considerations of each hospital and health system, at times CDUs provide great benefit in being able to flexibly accommodate inpatient holds, pre or postoperative patients, or additional acute ED treatment space as the need allows.  Design and construction with this in mind may enable the hospital to best accommodate ever changing dynamics - COVID being one example.

References

1. Emergency Medicine Network (EMNet). National Emergency Department Inventory – USA. https://www.emnet-usa.org/research/studies/nedi/nedi2018/. Accessed 1 Jan 2021.

2. Emergency Department Benchmarking Alliance (EDBA). Before there was COVID - 2019 Emergency Department Performance Measures Report. Accessed 1 Jan 2021.

3. Baugh CW, Liang L-J, Probst MA, Sun BC. National Cost Savings From Observation Unit Management of Syncope. Academic Emergency Medicine. 2015;22(8):934-941. doi: 10.1111/acem.12720.

4. Baugh, C. W., Venkatesh, A. K., & Bohan, J. S. (2011). Emergency department observation units: a clinical and financial benefit for hospitals. Health care management review, 36(1), 28-37.

5. Baugh and Granovsky - ACEP Now - https://www.acepnow.com/article/new-cms-rules-introduce-bundled-payments-for-observation-care/?singlepage=1

6. Making Greater Use Of Dedicated Hospital Observation Units For Many Short-Stay Patients Could Save $3.1 Billion A Year. Health Affairs. 2012;31(10):2314-2323. doi: 10.1377/hlthaff.2011.0926.

7. Ross MA, Hockenberry JM, Mutter R, Barrett M, Wheatley M, Pitts SR. Protocol-driven emergency department observation units offer savings, shorter stays, and reduced admissions. Health Aff (Millwood). 2013;32(12):2149-2156. doi: 10.1377/hlthaff.2013.0662.

8. Rydman RJ, Zalenski RJ, Roberts RR, et al. Patient satisfaction with an emergency department chest pain observation unit. Ann Emerg Med. 1997;29(1):109-115. doi: 10.1016/s0196-0644(97)70316-0.

Timothy Loftus, MD, MBA

Assistant Professor

Department of Emergency Medicine

Northwestern University

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Blenden, M. Wessling, E. (2021, Apr 12). ED Clinical Decision Making Units. [NUEM Blog. Expert Commentary by Loftus, T]. Retrieved from http://www.nuemblog.com/blog/ed-clinical-decision-making-units.

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ED Boarding

Written by: Julian Richardson, MD (PGY-3) Edited by: Luke Neill, MD (PGY-4) Expert commentary by: Tim Loftus, MD, MBA

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Emergency Department Boarding

Emergency Department boarding is the process of holding patients in the Emergency Department after the decision is made to admit the patient due to a lack of inpatient beds. 

Although boarding is often viewed as a problem specific to the Emergency Department, in actuality it represents a hospital wide problem which requires a concerted institutional effort to solve. 

 A True Medical Emergency

Obstructive Shock

An institution encountering boarding must ensure to treat it as the true medical emergency that it is. Using this line of thinking, boarding can be thought of as analogous to obstructive shock. When the hospital is in a shock state, the Emergency Department is unable to effectively “circulate” patients through the hospital. As the demand for hospital beds outstrips supply, boarding becomes even worse, similar to the lactate elevation when tissue demand for oxygen cannot be met. As boarding worsens further, the Emergency Department soon becomes a heart in full cardiac tamponade. Emergent intervention is required to prevent this from occurring.

What Contributes to Boarding?

Some Emergency Department level variables that have been found to be associated with longer boarding times are hospitals located in an urban location, hospitals in the northeast, and the proportion of non-Hispanic blacks, though this may be a confounder with urban location. Emergency Departments with longer boarding times have a disproportionate number of patient visits, higher proportions of urgent visits, longer wait times to be seen, higher average hospital occupancies, greater hospital admission rates, and longer lengths of stays in the hospital. Specific patient characteristics that contribute to boarding are older age, arrival by EMS, and need for advanced imaging. Specific patient characteristics not associated with boarding are sex, race, payer type, triage category, ICU admissions, and whether a patient was seen by a resident or intern.

Why Do We Care About Emergency Department Boarding?

Emergency Department boarding has serious consequences including an increase in patient mortality. A study by Sun et al found that patients had a 5% greater risk odds of inpatient death. This study also showed that these conditions led to longer lengths of stay, a 1% increased cost per admission. Over a 1 year period that analyzed approximately 1 million patient visits, there were 300 inpatient deaths, 6,200 hospital days, and $17 million in costs that could be attributed to Emergency Department boarding.

How Can We Solve This Issue?

To intervene, an organization must recognize where to place its resources. Eliyahu Goldratt introduced the theory of constraints in “The Goal”, which is a methodology used to identify the most important limiting factor when encountering a problem. When analyzing Emergency Department boarding, it is clear that it is an output problem. When patients are unable to move out of the Emergency Department, a bottleneck is soon created.

ACEP has investigated high impact solutions to ED boarding as shown below which provides a great foundation upon which to build solutions: 

High Impact Solutions 

- Moving patients who had been admitted but boarding to inpatient spaces

- Coordinate discharges before noon

- Coordinate schedules of elective and surgical patients

Additional Solutions

- Bedside registration

- Fast track units: moving patients with non-urgent medical solutions to a separate area of the emergency department

- Observation units

- Physician triage

Ineffective Solutions

• Expanding the emergency department to increase capacity

  • Observation units have been found to be more effective

• Ambulance diversion

  • Harmful to patients and ineffective

Although there is no one perfect solution, with a concerted effort by an entire healthcare organization, we hope to see the permanent resolution of Emergency Department boarding in healthcare.

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Expert Commentary

Thank you to Doctors Richardson and Neill on this excellent, succinct summary of the challenges we face in the ED with inpatient boarding.  I would like to highlight a few key themes and summarize some thoughts.

Words Matter

Firstly, I would offer that words in this context matter, and the way we frame this message impacts our ability to create our “burning platform” (1), foster buy-in, and ignite change. As many emergency physicians and hospital leaders can attest, often the most difficult step in improving ED crowding and inpatient boarding is to create a unified vision with shared goals.  In that respect, this is not “ED boarding” but rather hospital or inpatient boarding leading to ED crowding. The verbiage of “ED boarding” creates the connotation that it is an ED problem and only up to us to solve. Rather, and more accurately, it is inpatient boarding in the ED, leading to ED crowding. Illustratively, a 2009 Government Accountability Office (GAO) report confirmed that the most important cause of ED crowding is the lack of access to inpatient beds (2). How we message this to leaders, create this burning platform, and speak to this concept with colleagues, learners, and patients is a purposeful choice to create this unified vision. 

What’s the Current State?

The most recent data from the Emergency Department Benchmarking Alliance (EDBA) (3) demonstrates the following aggregate numbers for ED’s similar to NMH (80-100k visits):

1. Median length of stay  for all ED patients 246 minutes 

2. 4.4% left without being seen (LWBS) – about ~3500 patients annually for 80k annual volume ED) (NB:  LWBS predictably increases in a linear fashion as ED waiting room time increases )

3. We are seeing more patients that are older, higher acuity, and subsequently receive more ED testing. 

4. 65% of hospital admissions come through the ED (compared to 10% direct admissions, 8% transfers, and 15% L&D)

5. Median boarding time 169 minutes (41% of ED LOS for admitted patients is boarding time)

As was mentioned, increased duration and incidence of boarding is associated with urban high-volume EDs as well as in those patients who arrive by EMS, during office hours, are older, and receive advanced imaging (2). Longer boarding time is associated with higher volumes, acuity, and admission rates; longer hospital lengths of stay, and being seen by a resident or intern (2). 

A critical framework to consider in this current state  is the possible return on investment for various solutions.  One adage is that “the cheapest hospital bed is the one in the ED hallway,” which gets at the concept that boarding in the ED is so prevalent because hospitals maximize revenue by prioritizing non-ED admissions at the expense of caring for inpatients in ED hallways.  One study (4) looked at this, using a high volume urban academic hospital with a typical revenue of non-ED admissions double that of ED admissions, and the authors found that by reducing boarding time by 1 hr it would result in $9k-$13k additional daily revenue from capturing LWBS and diverted patients.  To meet this additional ED demand, dynamic bed management policies were simulated, and the optimal strategy that reduces ED boarding time, LWBS, and diverted patients, increasing ED arrivals, and optimizing non-ED admissions would generate an additional $2.7 to $3.6M annual revenue. 

Boarding Effects on Patients

Why such a fuss?  Other than lack of control over the clinical environment being a leading driver of burnout among physicians, (5) EM near the top with respect to prevalence of burnout, (6) and burnout contributing to detrimental patient-centered outcomes, there are additional patient-centered outcomes that are directly impacted – negatively – by inpatient boarding in the ED.  

If you take nothing else away from this topic, here is the punchline:

Boarding inpatients in the ED causes care delays, adverse outcomes across a variety of conditions,7 increased medication errors, (8) increasing rates of delirium, (9) worsens door to doctor time, increases ED LOS for all ED patients, increases inpatient LOS, and worsens hospital mortality.10  Put another way – boarding inpatients in the ED causes death. 

Solutions

Alas, it is not all doom and gloom.  Solutions are many but variable in use and impact.  As many would offer, change starts with us. ED presence and leadership in these discussions and initiatives is a necessity. Leading with persistence, effective communication, advocacy, empathy, and the ability to tell a story that is patient-oriented to drive change and create our burning platform is a must. 

One study (11) found that no single strategy was consistently effective at alleviating hospital boarding and ED crowding. Rather, four broad organizational characteristics were associated with better ED performance – a direct surrogate for hospital performance – senior executive involvement, hospital-wide strategies, data-driven management, and performance accountability.  In high performing hospitals, executives identified crowding as a top priority, clearly articulated performance goals, provided resources, and had leadership on the floor to monitor performance. 

Further, researchers at one community ED in the Kaiser system found that a hospital leadership-based program aimed at reducing admit wait times was associated with a significant decrease in boarding time, ED LOS, LWBS rate, and ambulance diversion as well as an increase in patient experience (12). 

More strategically speaking, surgical schedule smoothing has been shown to significantly impact boarding times and ED crowding, among a bevy of other financial and operational metrics (13-14). 

Full capacity protocols (FCPs), such as Beds in Progress (BIP) has demonstrated safety, success, and satisfaction (15). Patients prefer to board in the inpatient hallway rather than the ED, and yet only 20% of hospitals have successfully implemented this strategy (16-17).

ED Admissions, Hospital Discharges, and Flow

Strategies to optimize a variety of constraints in this process are numerous and often innovative, including interventions such as discharges by 10 or 11, post acute care preferred provider networks to facilitate disposition in those who require advanced rehab or nursing services, multidisciplinary outpatient pathways (low risk chest pain or TIA, AFib, VTE, pneumonia, sickle cell), community paramedicine, health system capacity alignment utilizing command centers and throughput committees, and optimizing demand-capacity alignment in the inpatient setting (timely and effective consults, procedures, tests, etc).  All have shown varying degrees of impact, safety, and success in improving hospital boarding and ED crowding (10,18).

Fixing Our Shop First

In the end, successful physician leaders have demonstrated excellent clinical acumen as well as a track record of leadership within their own environment.  Effective change management, engagement, and creation of a “burning platform” will fall on deaf ears unless we demonstrate an endless desire, effort, and dedication towards optimizing ED operations.  Successful strategies, endorsed by national organizations such as IHI or ACEP and grounded in LEAN thinking, include those as you have mentioned above including: direct bedding with bedside triage and registration, separating flows such as fast tracks, super tracks, vertical 3’s, or split flow models, provider in triage (PIT), CDU creation and optimization, and aligning demand-capacity relationships can all effect powerful change, improve ED LOS, decreased LWBS, decrease wait times, and improve patient and staff experience. 

Strategies to Avoid

Framing this issue as ED Boarding, and thus an ED problem that is up to the ED to solve, is often a short-sighted and limited perspective.  Placing the blame entirely on the ED, or even the patients who choose to utilize the ED, can create winds of change around initiatives with little or no impact such as diverting low acuity patients, financially disincentivizing care ambulance diversion or increasing ED bed capacity.19

Thank you again to Doctors Richardson and Neill for summarizing a topic of perhaps the most importance to emergency physicians, as we attempt to drive change around the concepts of flow, boarding, and crowding for the safety and satisfaction of ourselves and our patients. 

Literature Cited:

1. Guarisco J. Cracking the code: fixing the crowded emergency department, part 1 –building the burning platform. CommonSense 2013;September/October. 18-20. https://www.aaem.org/resources/publications/common-sense/right-column-items/cracking-the-code/archive

2. Pitts SR, Vaughns FL, Gautreau MA, Cogdell MW, & Maisel Z. A cross-sectional study of emergency department boarding practices in the United States. Acad Emerg Med. 2014;21:497-503. 

3. ED Benchmarking Alliance. 2018 Emergency Department Performance Measures. https://www.edbenchmarking.org/ 

4. Pines JM, Batt RJ, Hilton JA, & Terwiesch C. The financial consequences of lost demand and reducing boarding in hospital emergency departments. Ann Emerg Med. 2011;58:331-340. 

5. West CP, Dyrbye LN, Shanafelt TD. Phyisican burnout: contributors, consequences and solutions. J Intern Med. 2018;283(6):516-529.

6. Medscape National Physician Burnout, Depression, and Suicide Report 2019. 

7. Pines JM, Pollack CV, Diercks DB, Chang AM, Shofer FS, & Hollander JE. Association between emergency department crowding and adverse cardiovascular outcomes in patients with chest pain. Acad Emerg Med. 2009;16:617-625.

8. Kulstad EB, Sikka R, Sweis RT, Kelley KM, & Rzechula KH. ED overcrowding is associated with an increased frequency of medication errors. AJEM.2010;28:304-309. 

9. Singla A, Sinvani L, Kubiak J, Calandrella C, Brave M, Li T, et al. Emergency department hallway bed time is associated with increased hospital delirium. Ann Emerg Med. 2019;74(4S):S33. 

10. Morley C, Unwin M, Peterson GM, Stankovich J, & Kinsman L. Emergency department crowding: a systematic review of causes, consequences, and solutions. PLoS ONE. 2018;13(8):e0203316. 

11. Chang AM, Cohen DJ, Lin A, Augustine J, Handel DA, Howell E, et al. Hospital strategies for reducing emergency department crowding: a mixed-methods study. Ann Emerg Med. 2018;71:497-505. 

12. Patel PB, Combs MA, & Vinson DR. Reduction of admit wait times: the effect of  a leadership-based program. Acad Emerg Med. 2014;21:266-273. 

13. Litvak E. Innovations: surgical smoothing. Urgent Matters. https://smhs.gwu.edu/urgentmatters/news/innovations-surgical-smoothing

14. Ryckman FC, Adler E, Anneken AM, Bedinghaus CA, Clayton PJ, Hays KR, et al. Cincinnati Children’s Hospital Medical Center: redesigning perioperative flow using operations management tools to improve access and safety. In Managing Patient Flow in Hospitals: Strategies and Solutions. 2nd ed. 97-111. 

15. Vicellio A, Santora C, Singer AJ, Thode HC, Henry MC. The association between transfer of emergency department boarders to inpatient hallways and mortality: a 4-year experience. Ann Emerg Med. 2009;54:487-491. 

16. Garson C, Hollander JE, Rhodes KV, Shofer FS, Baxt WG, & Pines JM. Emergency department patient preferences for boarding locations when hospitals are at full capacity. Ann Emerg Med. 2008;51:9-12. 

17. Vicellio P, Zito JA, Savage V, et al. Patients overwhelmingly prefer inpatient boarding to emergency department boarding. J Emerg Med. 2013;45(6):942-946. 

18. ACEP EM Practice Committee. 2016. Emergency department crowding: high impact solutions. 

19. Han JH, Zhou C, France DJ, Zhong S, Jones I, Storrow AB, et al. The effect of emergency department expansion on emergency department overcrowding. Acad Emerg Med. 2007;14:338-343.

Timothy Loftus

Assistant Professor

Department of Emergency Medicine

Feinberg School of Medicine

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References

1.     Ramlakhan, S., Qayyum, H., Burke, D., & Brown, R. (2015). The safety of emergency medicine. Emerg Med J. doi: 10.1136/emermed-2014-204564

2.     Asplin, B. R., Magid, D. J., Rhodes, K. V., Solberg, L. I., Lurie, N., & Camargo, C. A., Jr. (2003). A conceptual model of emergency department crowding. Ann Emerg Med, 42(2), 173-180. doi: 10.1067/mem.2003.302

3.     ACEP. (2008). Emergency department crowding: high-impact solutions.

4.     Pitts, S. R., Vaughns, F. L., Gautreau, M. A., Cogdell, M. S., & Meisel, Z. (2014). A cross-sectional study of emergency department boarding practices in the Unites States Academic emergency medicine, 21(5), 6.

5.     Sun, B. C., Y., H. R., Weiss, R. E., Zingmond, D., & Han, W. (2013). Effect of emergency department crowding on outcomes of admitted patients. Ann Emerg Med, 61(6), 6.

6.     Vieth, T. L., & Rhodes, K. V. (2006). The effect of crowding on access and quality in an academic ED. Am J Emerg Med, 24(7), 787-794. doi: 10.1016/j.ajem.2006.03.026

7.     Carter, E. J., Pouch, S. M., & Larson, E. L. (2013). The relationship between emergency department crowding and patient outcomes: a systematic review. Journal of Nursing Scholarship, 46(2), 9.

8.     Blom, M. C., Jonsson, F., Landin-Olsson, M., & Ivarsson, K. (2014). The probability of patients being admitted from the emergency department is negatively correlated to in-hospital bed occupancy - a registry study. International Journal of Emergency Medicine, 7(8), 7.

9. Schull, M. J., Lazier, K., Vermeulen, M., Mawhinney, S., & Morrison, L. J. (2003). Emergency department contributors to ambulance diversion: a quantitative analysis. Ann Emerg Med, 41(4), 467-476. doi: 10.1067/mem.2003.23

10. Falvo, T., Grove, L., Stachura, R., & Zirkin, W. (2007). The financial impact of ambulance diversions and patient elopements. Acad Emerg Med, 14(1), 58-62. doi: 10.1197/j.aem.2006.06.056

11. Han, J. H., Zhou, C., France, D. J., Zhong, S., Jones, I., Storrow, A. B., & Aronsky, D. (2007). The effect of emergency department expansion on emergency department overcrowding Academic emergency medicine, 14(4), 6.

12. Grouse, A. I., Bishop, R. O., Gerlach, L., de Villecourt, T. L., & Mallows, J. L. (2014). A stream for complex, ambulant patients reduces crowding in an emergency department. Emerg Med Australas, 26(2), 164-169.

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How to Cite this Post

[Peer-Reviewed, Web Publication] Richardson, J, Neill, L. (2020, Mar 30). ED Boarding. [NUEM Blog. Expert Commentary by Loftus, T]. Retrieved at https://www.nuemblog.com/blog/ed-boarding

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