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Evidence Reports All of EHC
Evidence Reports All of EHC



Emergency Department Crowding

NOMINATED TOPIC | June 2, 2023

1. What is the decision or change (e.g., clinical topic, practice guideline, system design, delivery of care) you are facing or struggling with where a summary of the evidence would be helpful?

For decades, some emergency departments have struggled with boarding inpatients (hospital overflow) leading to delays in care and errors for boarded and general ED patients as well as patient harm, frustrations, and dissatisfaction. With the current nursing shortage in both hospitals and long-term care, boarding of inpatients is now present in nearly all emergency departments in the US and across the world.

Nearly all emergency patients (140 million per year) are affected with delays of care, increased noise, care in hallways or waiting rooms. Harms to the patient have been reported in a number of papers, but rarely collated in one source. These harms include the effect on time sensitive conditions such as stroke and acute myocardial infarction in boarded patients and in ED patients awaiting care and evaluation. There is an increase in delirium among older patients boarded in the chaotic environment of the ED. In addition there is evidence that strongly suggests increased cost and increase in length of stay in patients who are boarded.

2. Why are you struggling with this issue?

To date, solutions to ED crowding have focused on ED efficiency, however the current problem rests in hospital overflow. There is significant variation in dealing with hospital overflow, with some instituting 6 or 7 day a week services to smooth the surgical schedule, placing in patients in inpatient hallways, and planning for earlier discharge of inpatients. However, the vast majority of hospitals use none of these.

Existing studies have articulated the harm and cost in a specific institution but rarely across institutions. Other studies have investigated the consequences of specific solutions. However, no study has looked across multiple institutions and linked these to the outcome of solutions.

We need to better understand, synthesize, collate, and disseminate the root causes of boarding, the patient harms that result including increased errors, increase cost and delays in care, and the harm to the ED staff with moral injury and the effect on burnout. We need to better understand and convince stakeholders of the cost consequences to the institution, to the payers and to the government. Finally, we need to consider potential solutions and their effect on patients, staff and payment.

3. What do you want to see changed? How will you know that your issue is improving or has been addressed?

Most first-world countries (e.g., Canada, UK, Australia) have addressed this issue by ‘load-level', spreading the overflow throughout the hospital, and imposing strict limits on ED length of stay. Though not 100% effective, boarding times have been reduced. The US however is not addressing this issue. Success would be easily measured using ED length of stay timestamps, improved transfer time from rural hospital and a decrease in delirium/length of stay for elders.

Ideally change would address the root cause of using the ED as the primary site of hospital overflow. It would also address the increasingly common issue of rural EDs that hold (and care for) admitted patients who need tertiary level of care and timely interfacility transport when the referral institution is full.

4. When do you need the evidence report?

Tuesday, April 30, 2024

5. What will you do with the evidence report?

To date efforts to reduce boarding and therefore patient harm has been at the institutional level, and largely failed. Efforts now need to broaden recognition and focus on regional and national efforts. We will use the evidence to encourage CMS and The Joint Commission to address boarding. Our Advocacy meeting is in May 2024 and will be used to promote a boarding bill (already introduced this year). We will also use it to provide support for a Federally sponsored Summit on Boarding.

This report will also support efforts to create a ‘boarding measure’. The Joint Commission and CMS had a boarding standard in the past, but few hospitals chose to report it, and the standard was easily ‘gamed’. This standard has now been sunsetted.

Optional Information About You

What is your role or perspective? physician professional society

If you are you making a suggestion on behalf of an organization, please state the name of the organization - American College of Emergency Physicians

May we contact you if we have questions about your nomination? Yes

Page last reviewed June 2023
Page originally created June 2023

Internet Citation: Emergency Department Crowding. Content last reviewed June 2023. Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD.

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