Homeward Bound: Acute Hospital Care at Home

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Written by: Pranav Kaul, MD (NUEM ’25) Edited by: Gabrielle Bunney, MD, MBA (NUEM ’22)

Expert Commentary by: Luke Neill, MD, MBA (NUEM ’20)

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Hospitals and acute care medicine are historically inseparable. However, with hospital-based care totaling nearly one-third of national health expenditures in the United States annually, increasingly limited bed capacity1, and evidence suggesting hospitalizations are unsafe for many elderly patients2, it is no surprise that administrators and policymakers are seeking innovative alternatives to inpatient medicine.  

Currently, for some of the most common conditions, that alternative exists. The acute hospital care at home or “AHCaH” model seeks to bring acute care services (e.g. continuous monitoring, 24-hour provider availability, intravenous medications) to the patient’s home in an effort to allocate health system resources more appropriately relative to patient needs. New evidence suggests that the “hospital at home” model may have cost and quality benefits over traditional hospitalization, strengthening the push for this approach to be adopted more widely. Today, we examine a 2020 randomized-controlled trial from Annals of Internal Medicine comparing the impact of a home hospitalization pilot program on cost and quality of care.  

Study: Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial  

Study Design: Parallel design, randomized controlled trial  

Population:  

• 91 adults (43 home and 48 control) admitted via the emergency department with selected acute conditions  

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Intervention:  

• Acute care at home including nurse and physician home visits, intravenous medications, remote monitoring, video communication, and point-of-care testing  

Outcome Measures:  

• Primary: total direct cost of acute care episode (sum of non-physician labor, supplies, medications, and diagnostic tests)  

• Secondary: health care use, physical activity during the episode and at 30 days  

Results:  

• Primary: 38% lower adjusted mean cost for home patients vs control including fewer diagnostics and consultations.  

• Secondary: Smaller proportion of day spent sedentary or lying down; fewer 30-day readmissions (7% vs 23%)  

Discussion/Conclusions:  

This study sought to compare cost, quality, and experience outcomes between patients who received “home hospital care” and those who were admitted to the hospital. Using broad inclusion and exclusion criteria that incorporated physician judgment, patients were enrolled and randomized to either the intervention (home hospital care) or control (inpatient hospital) at admission.  

When comparing costs, the intervention group had a 38% lower adjusted means cost than the control, including fewer laboratory orders, imaging studies, and consultations. Moreover, patients who received acute care at home had significantly lower 30-day readmission rates (7% vs. 23%). Overall, quality and patient satisfaction outcomes were largely similar between the two groups.  

Despite these promising results, home hospital care is an evolving field of research that warrants further investigation. While this study suggests that cost and readmission reductions can be achieved without compromising care quality, it is important to recognize its limitations. Inclusion and exclusion criteria were dependent on subjective assessments by admitting providers, which limits generalizability of the findings. Without a standardized protocol to select appropriate patients, it will be challenging to implement. Among patients that were selected for inclusion, approximately 63% opted out of the study. A broad set of conditions were included without any stratification, and patients were carefully selected for “low risk of clinical deterioration.” Consequently, the small sample size and case distribution may have also limited the study’s power and ability to accurately capture safety events in either group. 

Home hospital care presents many possible advantages to patients, payors, and providers, but it continues to seek comprehensive and generalizable data to support its widespread implementation. Studies such as this one provide a strong foundation for further research into this area through larger trials and systematic reviews.  

References:

1 Horwitz LI, Green J, Bradley EH.US emergency department performance on wait time and length of visit. Ann Emerg Med. 2010;55:133-41.  [PMID:  19796844]  doi:10.1016/j.annemergmed.2009.07.023  

2 Hung WW, Ross JS, Farber J, et al.Evaluation of the Mobile AcuteCare of the Elderly (MACE) service. JAMA Intern Med. 2013;173:990-6. [PMID: 23608775] doi:10.1001/jamainternmed.2013.478  

3Levine DM, Ouchi K, Blanchfield B, Saenz A, Burke K, Paz M, Diamond K, Pu CT, Schnipper JL. Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial. Ann Intern Med. 2020 Jan 21;172(2):77-85. doi: 10.7326/M19-0600. Epub 2019 Dec 17. PMID: 31842232. 

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Expert Commentary

Launched in 2020 by the Center for Medicare and Medicaid Services (CMS), the Acute Hospital Care at Home program allows patients to receive inpatient level care within their own home.  A patient can be admitted to home through two main mechanisms: 

1. The Patient can be admitted directly to home from the Emergency Department 

2. A patient who was initially admitted to the floor can be transferred early to acute inpatient care at home to finish the remainder of their admission.   

 In order to begin enrolling patients in the program, each individual hospital must submit an Acute Hospital Care At Home Waiver to CMS and receive approval. Northwestern Memorial Hospital received approval for the waiver back on March 27th of 2021 and after spending a year building the infrastructure of the program, admitted the first patient into both our program and within Chicago on March 27th of 2022.     

 As of February 2024, there are now 131 systems including 313 hospitals in 37 states, and CMS closely monitors these programs. Health systems interested in the program can learn more here. 

Unequivocal Program Benefits:  

  Acute Care at Home Models Reduce Costs - In general, acute care at home programs have realized savings of 30 percent or more per admission, while maintaining equivalent or better outcomes.1 

  Acute Care at Home Models Improve Quality – Quality results for care in the home are comparable to or better than those realized for facility-based care. Programs have demonstrated a reduction in readmissions, mortality, complications, and emergency department visits.2,3 

 Consumers Prefer to Receive Care in the Home – Home-based care is preferred by the overwhelming majority.4 

 Home-Based Models Contribute to Improving Disparities and Trust – Home-based models provide marginalized communities the option to conveniently receive care at home, which helps to reduce barriers to facility-based care such as access to transportation. Home-based care also promotes trust and communication between the patient and provider by removing institutional barriers and placing the interaction in a familiar setting.4 

References 

1. Adams D, et al. Initial Findings From an Acute Hospital Care at Home Waiver Initiative. JAMA Health Forum. 2023;4(11)​​Levine DM, et al. Acute Hospital Care at Home in the United States: The Early National Experience. Ann Intern Med. 2024 Jan;177(1):109-110.  

2. Levine DM, et al. Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial. Ann Intern Med. 2020 Jan 21;172(2):77-85.​​ 

3. Federman AD, Association of a Bundled Hospital-at-Home and 30-Day Postacute Transitional Care Program With Clinical Outcomes and Patient Experiences. JAMA Intern Med. 2018;178(8):1033–1040.​ 

4. Leff B et. al. Satisfaction with hospital at home care. J Am Geriatr Soc. 2006 Sep;54(9):1355-63​ 

Luke Neill, MD, MBA

Director, Hospital at Home Program

Emergency Medicine

Northwestern Memorial Hospital

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Kaul, P, Bunney, G (2024, May 20). Acute Hospital Care at Home. [NUEM Blog. Expert Commentary by Neill, L. Retrieved from http://www.nuemblog.com/blog/hospital-care-at-home

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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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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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Mobile Integrated Health

Written by: Ezekiel Richardson, MD (NUEM ‘23) Edited by: Alex Herndon, MD (NUEM ‘21) Expert Commentary by: Hashim Zaidi, MD

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Introduction

Community Paramedicine, also known as Mobile Integrated Health (MIH), is a developing field in which paramedics and emergency medical technicians assist under-resourced areas in the provision of public health, primary healthcare, and preventive services. The express goal of these services is to “improve access to care and avoid duplicating existing services.” [1] While community paramedicine was pioneered in rural settings in which distance significantly limited the patients’ access to primary care and public health, it has continued to expand from rural areas that are underserved into underserved suburban and urban centers.

Across the nation, community paramedicine has taken on may roles, from providing primary prevention and onsite triage in Minneapolis, targeting emergency medicine “hot spots” for prevention of 911 calls in Ontario, to leveraging telemedicine to allow a physician to triage 911 dispatches, paramedic assessment, and diverting patients to primary care in Houston. [2,3,4]

In the United States we have seen a slow and steady migration of low-income individuals out of cities. Nearly 60% of all low-income individuals live outside the city limits of the nearest metropolitan area. [5] Suburban poverty has increased by half in most major metropolitan cities including Chicago. [6] Notably, a significant amount of literature suggests that wealthy and middle class suburbs (whose health infrastructure was built to support individuals with income and agency) are now facing a massive migration of low-income citizens. [7, 8] Accordingly, new healthcare solutions like MIH will be of paramount importance as trends in American migration continue as they have over the last 50 years.

In places like Houston, Minneapolis, and Ohio City where a single healthcare system captures a large share of the patient population and sees a significant amount of the costs from ambulance runs, those healthcare systems have funded community paramedics to assess high-volume patients and if medically appropriate, divert them triggering an ambulance run to the Emergency Department. [2, 4, 9]

In Minneapolis, this was done by staffing a community paramedic at a homeless shelter and community shelter that saw frequent ambulance calls and transports after clients left for the night and may have forgotten medications, developed asthma exacerbations, or minor injuries. [2]

In Houston, telemedicine equipment and a part time emergency medicine physician allowed remote evaluation in a patient’s home with a walk around tour a referral for certain home care services, medication refills, and primary care appointments.4 Houston’s program showed significant improvement in efficiency. Of the 5,570 patients participated, 18% received ambulance transport as opposed to 74% and EMS crews returned to service 44 minutes faster than prior. [10]

In Ohio City, frequent fliers who have called and been transported to the emergency department more than 10 times in 24 months will be given the option to have community paramedics perform a home assessment and ensure that they have the equipment and primary care to avoid emergency department visits. [7]

In Ontario, a community paramedic was stationed in a random apartment building selected for high volume and proportion of elderly individuals and a high frequency of EMS calls. There the paramedic was able to assess the health of residents, answer questions, and provide basic health education, as well as had the ability to activate emergency transport and provide basic primary care. The intervention showed evidence of an increase in the amount of Quality Adjusted Life Years, a decrease in blood pressure among study participants, as well as a significant decrease in EMS calls, thus making a difference in both patient health outcomes and proper utilization of emergency health systems. [11]

Conclusions

While community paramedicine is a promising new intervention as populations age and migrate out from urban centers, there is still sparse data on its success. Even the data that does exist raises serious questions about reproducibility from both a clinical results standpoint and an intervention oversight. However, community paramedicine’s strength may be in its flexibility and the freedom of enterprising EMS directors, public health, and city safety officials to tailor a program to a city’s needs and available budget.

Limitations

In Minneapolis, the community paramedicine program was not renewed because of difficulty quantifying cost savings and proving financial feasibility. Ohio City’s program is too early to yield results. Houston’s program and Ontario’s program have produced literature supports the notion that paramedicine can reduce EMS calls and costs spent on transportation and emergency evaluation.

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Expert Commentary

Thank you to the authors for touching on a critical subject that has only become even more important during a global pandemic. Mobile Integrated Healthcare (MIH) – also known as Community Paramedicine – shows significant promise in providing resources to those disenfranchised from healthcare.

The 1996 EMS Agenda for the Future calls for EMS to one day serve as “community-based health management that is fully integrated with the overall health care system…integrated with other health care providers and public health and public safety agencies. It will improve community health and result in more appropriate use of acute health care resources. EMS will remain the public’s emergency medical safety net.” Nearly a quarter of a century later we are getting the necessary footholds to move this vision from fantasy to reality while still recognizing the need for EMS as the public’s emergency medical safety net. The Center for Medicare & Medicaid Services (CMS) has recognized the value of leveraging existing EMS resources to further the mission of community-based health management.

The ET3 model unveiled earlier this year by CMS describes a 5-year payment model that will pay participating EMS services for 1) transport an individual to a hospital emergency department (ED) or other destination covered under the regulations, 2) transport to an alternative destination partner (such as a primary care doctor’s office or an urgent care clinic), or 3) provide treatment in place with a qualified health care partner, either on the scene or connected using telehealth. This shows the promise of incentives to reduce unnecessary transports but also to reimburse for services rendered by EMS. This applies in novel interventions such as mobile integrated healthcare but also in more common scenarios. Imagine what a model such as this could do with those who are quarantined at home or in shelters with COVID but require regular telehealth check ups for chronic disease management. Or even more simply, community members who need someone to help ensure they have food and running water.

MIH is a promising field that builds on the foundation of EMS being a community-based healthcare entity as opposed to a patient transportation service. MIH, particularly for the most vulnerable populations frequently served by EMS and the ED, stand to benefit the most with models such as this. EMS has come a long way from “you call, we haul” and initiatives such as MIH should be supported and financially fostered in communities by local and state agencies.

Hashim Zaidi, MD

McGovern Medical School

Assistant Professor

Harris Health System

Medical Director

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Richardson, Ezekiel. (2021, Jan 4). Mobile Integrated Health [NUEM Blog. Expert Commentary by Zaidi, H]. Retrieved from http://www.nuemblog.com/blog/mobile-integrated-health

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References

1. https://www.cdc.gov/dhdsp/pubs/docs/SIB_Feb2019-508.pdf. (2020) Retrieved January 7, 2020

2. “Community Paramedicine: A Simple Approach To Increasing Access To Care, With Tangible Results, " Health Affairs Blog, October 31, 2017. DOI: 10.1377/hblog20171027.424417

3. Dainty, K. N., Seaton, M. B., Drennan, I. R., & Morrison, L. J. (2018). Home visit‐based community paramedicine and its potential role in improving patient‐centered primary care: a grounded theory study and framework. Health services research, 53(5), 3455-3470.

4. Langabeer, J. R., II, M. G., Alqusairi, D., Champagne-Langabeer, T., Jackson, A., Mikhail, J., & Persse, D. (2016). Telehealth-enabled emergency medical services program reduces ambulance transport to urban emergency departments. Western journal of emergency medicine, 17(6), 713.

5. Kneebone, Elizabeth, and Garr, Emily. 2010. “The Suburbanization of Poverty: Trends in Metropolitan America, 2000 to 2008.” Metropolitan Opportunity Series. Brookings Institution, Metropolitan Policy Program. http://www.brookings.edu/~/media/research/files/papers/2010/1/20-poverty-kneebone/0120_poverty_paper.pdf.

6. Kneebone, Elizabeth, and Holmes, Natalie. 2015. “The Growing Distance Between People and Jobs in Metropolitan America.” Brookings Institution, Metropolitan Policy Program. http://www.brookings.edu/~/media/research/files/reports/2015/03/24-job-proximity/srvy_jobsproximity.pdf.

7. Allard, Scott W., and Sarah Charnes Paisner. "The rise of suburban poverty." (2016).

8. Kneebone, E. (2014). The growth and spread of concentrated poverty, 2000 to 2008-2012. The Brookings.

9. Frolik, C., & Tribune News Service. (2019, December 30). Ohio City to Launch MIH-CP Program to Cut Down on Frequent Flyers. Retrieved from https://www.emsworld.com/news/1223715/ohio-city-launch-mih-cp-program-cut-down-frequent-flyers.

10. JEMS. (2020). The Impact of Telehealth-Enabled EMS on Ambulance Transports - JEMS. [online] Available at: https://www.jems.com/2017/08/01/the-impact-of-telehealth-enabled-ems-on-ambulance-transports/ [Accessed 11 Jan. 2020].

11. Agarwal, G., Angeles, R., Pirrie, M., McLeod, B., Marzanek, F., Parascandalo, J., & Thabane, L. (2019). Reducing 9-1-1 emergency medical service calls by implementing a community paramedicine program for vulnerable older adults in public housing in Canada: a multi-site cluster randomized controlled trial. Prehospital Emergency Care, 1-12.

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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