Administration & Operations, Health Care Administration

Nowhere to Go: Addressing the Boarding Crisis in the Emergency Department

EMRA’s Administration & Operations Committee hosted a panel discussion titled “Nowhere to Go: Addressing the Boarding Crisis in the Emergency Department” at ACEP23 in Philadelphia. Panelists explored the critical issue ofovercrowding in EDs.

Boarded patients, who are often the most critically ill in the ED and require inpatient admission, create competition for ED resources, leading to crowding. This crowding, in turn, results in delayed or unavailable resources for other incoming emergencies in the ED. This phenomenon transcends being a mere local concern, serving instead as a significant symptom of larger systemic issues within the health-care sector. The panel underscored the profound impacts of ED crowding on aspects such as patient safety, welfare of medical staff, and efficiency of health-care systems overall.

ED crowding experts leading the panel included:

  • Gabor Kelen, MD, chair of emergency medicine, The Johns Hopkins School of Medicine
  • Eric Legome, MD, chair of emergency medicine, Mount Sinai Morningside West
  • Lauren Nentwich, MD, vice chair for clinical affairs of emergency medicine, Massachusetts General Hospital
  • Andrew Leubitz, DO, MBA, US Acute Care Solutions

During this pivotal panel discussion, leading experts urgently called for a paradigm shift in how ED crowding is perceived and addressed. Far from being a mere inconvenience, ED crowding poses a serious threat to patient safety, demanding immediate and concerted attention.

Hospitals across the nation, regardless of size, have witnessed a significant increase in ED boarding, leading to compassion fatigue among clinicians. Dr. Legome emphasized the national scale of this issue, stressing the scarcity of resources and the necessity for a collective response to understand and address the root causes.

Panelists united in their view that ED crowding should not be an unexpected crisis but a foreseeable and manageable challenge. They strongly advocated for the adoption of proactive surge plans, comparable to those used in disaster response, to effectively counteract the detrimental effects of crowding.

Contributing Factors
Building on the understanding of ED crowding as a critical issue, the panel discussion delved into causes and contributing factors, revealing a complex interplay of hospital efficiency, economic challenges, and staffing issues.

Hospital Crowding and Efficiency
A key factor identified was the critical threshold of hospital utilization impacting safety and efficiency. The panel outlined a clear delineation: Hospitals operate optimally at an occupancy rate below 85%, ensuring that waiting areas remain manageable and the number of patients awaiting beds (boarders) is minimal. However, as the census climbs to 85-95%, the system becomes stressed, with increased boarding reducing ED functional space. Beyond 90%, extensive crowding leads to unsafe conditions, overcrowded waiting rooms, and the practice of “waiting room medicine.” This phenomenon aligns with queuing theory, where the challenge lies in matching fixed resources with unscheduled demand. Even the most efficient hospitals struggle to keep utilization below the critical 87% threshold, a testament to the complexity and severity of this issue.

Economic and Structural Challenges
Panelists highlighted the fundamental misalignment in health-care economics as a root cause. Hospitals, driven by financial incentives, prioritize patients contributing to revenue, creating bottlenecks in EDs and endangering patient safety. This misalignment extends to health-care financing, where skewed incentives and reimbursements exacerbate crowding. Dr. Legome emphasized that this issue is more accurately described as hospital, rather than ED, crowding. Inpatient wards fill up, causing backups in the ED, and not all available inpatient beds are allocated to ED patients. Compounding this are the challenges with skilled nursing facilities selectively admitting patients, decreased availability of hospice care, and lack of accessible primary care, all contributing to increased ED visits.

Furthermore, panelists drew a parallel between the situation in hospitals and the “tragedy of the commons,” a concept that illustrates how individual departments, by focusing on their own safety metrics and operational efficiency, may inadvertently amplify risks for patients in the ED. This occurs as other services, in an effort to protect their own operational integrity, inadvertently concentrate risks and burdens in the ED. This systemic problem underscores the need for a more integrated and holistic approach to hospital management, where the welfare of ED patients is given equal consideration in the broader context of hospital operations.

Staffing Issues and Patient-Care Concerns
Staffing challenges, including high turnover and burnout of vital staff, further exacerbate the situation. Panelists noted alarming incidents of violence against staff and mistrust of physicians as indicative of the immense strain on health-care workers. Dr. Kelen and Dr. Legome remarked on the worsening post-pandemic situation, highlighting how COVID-19 exacerbated boarding issues, staffing shortages, and reduced availability of nursing facilities and hospice care.

Overall, patient care is debilitated by the institution’s inability to keep up with the high volume of new ED patients in addition to the many boarders. Many doctors practice “waiting room medicine” in which they order a workup for a patient without a proper history and exam as a way to expedite care. Furthermore, in some regions of the country, nursing ratios are nonexistent, and a single nurse could be responsible for upwards of 25 patients at one time. Ultimately, these operational inefficiencies lead to increased morbidity and mortality, impacting both patient experience and health-care costs.

Proposed Solutions and Strategies
Continuing from a previous discussion on the complexities of ED crowding, the panel at ACEP23 shifted focus to potential solutions and strategies, emphasizing the inadequacy of traditional approaches and the need for innovative operational and systemic changes.

Operational Improvements
A key recommendation put forth by the panel, as articulated by Dr. Leubitz, was streamlining operational processes. A prime example of this is the simplification of patient intake forms, a seemingly small change that can significantly expedite efficiency and improve the flow of patients. This approach is part of a broader strategy to optimize hospital operations and mitigate ED congestion. Panelists strongly advocated for more dynamic management of inpatient capacity, aiming to prevent the critical overloads that often precipitate ED bottlenecks.

Another key strategy emphasized was the centralization of patient flow management across the hospital. By doing so, hospitals could more effectively coordinate their resources and capacities, ensuring a smoother and more efficient process for handling patient admissions and transfers. Dr. Nentwich proposed expanding patient care options, including implementing a home hospital program for delivering hospital-level treatment at home and establishing an EM program to manage high-utilizer patients, thereby reducing their frequent ED visits.

Systemic and Administrative Changes
In terms of systemic changes, Dr. Nentwich posited the critical need to integrate the ED more fully into the broader hospital capacity management decision-making. Panelists stressed the importance of fostering open lines of communication with various medical specialties. A novel approach discussed was the utilization of temporary boarding solutions in inpatient hallways, aimed at alleviating immediate space constraints.

Dr. Kelen also emphasized the crucial role of senior hospital leadership, especially hospital CEOs, in championing these changes. He specifically noted that visible commitment and proactive measures from top-level management are necessary for enacting meaningful and lasting change.

Another pressing issue raised was the marked increase in psychiatric cases, a concern highlighted by Dr. Leubitz. He advocated for the expanded use of telemedicine as a means to reduce the time from patient arrival to treatment. Additionally, he suggested enhancing disposition planning and considering options like community hospital transfers to manage this rise effectively. These recommendations reflect a deep understanding of the multifaceted challenges faced by EDs and underscore the panel’s commitment to finding innovative and practical solutions.

Staff Well-Being and Morale
The panel also focused on the importance of maintaining staff well-being and morale. Strategies to alleviate physician frustration were explored, with an emphasis on fostering a culture of gratitude and teamwork. Dr. Leubitz highlighted the importance of building connections with patients, while Dr. Nentwich stressed the need to prioritize staff experiences for retention and protection. Dr. Legome emphasized the crucial need for increased nursing resources. In the closing remarks, Dr. Kelen inspired physicians in the audience by reminding them of their invaluable role as health-care heroes, emphasizing self-recognition and resilience amid challenges.

Advocacy and Future Direction
Panelists emphasized the critical role of national-level advocacy in addressing emergency department crowding. They recognized the powerful influence of organized medicine and bodies like EMRA in driving systemic change. Panelists urged for concrete actions, calling for regulatory reforms from key institutions such as The Joint Commission (TJC), the Centers for Medicare & Medicaid Services (CMS), and the Accreditation Council for Graduate Medical Education (ACGME). These reforms should specifically address the consequences of ED crowding on patient safety, the potential rise in violence, and the adverse impact on staff well-being.

In summarizing challenges and potential solutions for ED crowding, the panel underscored the need for a collaborative, multifaceted approach. This strategy not only aims to improve ED operations but also focuses on enhancing the well-being of medical staff. Implementing these recommendations presents a tangible opportunity to evolve the health-care system into one that is more efficient, equitable, and patient-centered.

Related Articles

Meet Nicholas Stark, MD, MBA

We're pleased to introduce Nicholas Stark, MD, MBA, vice chair of the EMRA Admin & Ops Committee, 2020-2021.

Meet Nick Cozzi, MD, MBA

We're pleased to introduce Nick Cozzi, MD, MBA, chair-elect of the EMRA Admin & Ops Committee, 2020-2021.