Most emergency physicians would agree that boarding patients in the ED for hours or days while they wait for a hospital bed isn't good for them. And small studies from Canada, Australia, and U.S. hospitals have borne this out: They found an increased mortality rate among patients who experience delays in admission to an inpatient bed from the ED.
One of the largest studies to date has now confirmed this. Delays over four hours between ED admission and hospital admission are associated with a higher 30-day all-cause mortality rate independent of ED crowding. (Emerg Med J. 2022;39:168; https://bit.ly/3qSEJLz.) The investigators found the standardized mortality rate started to rise at five hours after the patient's ED arrival, and after six to eight hours, they estimated one extra death occurred within 30 days for every 82 patients delayed.
The investigators took advantage of the large data sets from England's National Health Service (NHS) to conduct a cross-sectional, comparative, retrospective, observational study of all patients admitted from all type 1 EDs between April 2016 and March 2018, more than five million patients. (Type 1 EDs are open 24 hours a day under the supervision of emergency medicine consultants.) They only included patients' first admission to the ED, noting that those with multiple ED admissions are known to have poorer outcomes that could have confounded the findings.
“The studies that have looked at this relationship previously have tended to be small, single-hospital studies, and we were in the ideal position to be able to do this across the whole nation,” said one of the study's lead authors, Simon Jones, PhD, a research professor of population health at NYU Grossman School of Medicine, who worked with colleagues from the Royal Bolton Hospital and Musgrove Park Hospital in the United Kingdom.
Dr. Jones and his group adjusted for age, gender, number of previous admissions, and time of visit. “We wanted to separate out the effect of waiting in the ED from overcrowding, so we also worked out the average waiting time for patients at the time the particular patient walked through the door,” he said. “Using NHS data, we can tell you that for any time of day, which is much more difficult to do in the U.S. We would also have loved to have more complicated measures of patient acuity, but the data wasn't reliable enough, so we had to rely on the coding of comorbidities and the number of past ED attendances as a proxy for acuity.”
The investigators' risk model found that waiting under four hours for hospital admission was definitely beneficial, the four- to five-hour window was a gray area, and an increase in mortality was seen beyond five hours. “If you wait four to eight hours, for every 72 patients, we see one additional death,” Dr. Jones said. “Between six and eight hours, for every 82 patients, we see one additional death.”
The group's findings jibe with outcomes seen shortly after the United Kingdom mandated in 2020 that all major NHS hospitals discharge, admit, or transfer at least 95 percent of patients within four hours of arrival. Most hospitals met that metric between 2011 and 2013, and patient mortality within a year of visiting the emergency department fell from nine percent to 8.7 percent, according to a 2020 report. (Institute for Fiscal Studies. Jan. 17, 2020; https://bit.ly/3SmDzDY.) The target resulted in around 15,000 fewer deaths in 2012 and 2013 alone.
Arjun Venkatesh, MD, an associate professor and the chief of emergency medicine at Yale University, who has written extensively on ED delays and their impact on care and outcomes, praised the study. “It makes a compelling case that when it comes to real patient-oriented outcomes, boarding times over five hours are clinically harmful,” he said.
Dr. Venkatesh and Scott Weiner, MD, an associate professor of emergency medicine at Harvard Medical School and the chief of health policy and public health in the department of emergency medicine at Brigham and Women's Hospital, criticized the federal Centers for Medicare and Medicaid Services' (CMS) August 2021 decision to abandon the metric of its Hospital Inpatient Quality Reporting Program for recording the median time from decision to admit an ED patient to their departure from the ED. (Health Affairs Forefront. March 29, 2022; https://bit.ly/3SfEDKd.)
Introduced in 2016, the measure had its flaws. It was only one of several measures that hospitals could choose to use in their data-reporting requirements, and all hospitals had to do was report but not improve their performance or meet any benchmarks. Rather than modifying the program to make better use of this metric, CMS dropped it entirely based on a study that Drs. Venkatesh and Weiner said was wholly misinterpreted.
CMS cited a review that was inconclusive about the harms of ED boarding. (PLoS One. 2020;15:e0231253; https://bit.ly/3dsqWIq.) “They didn't say boarding is not harmful, they just said that the results of studies had been mixed.” Dr. Venkatesh said. “And within that, they note there are several studies that have shown that for key populations, particularly those that are critically ill, boarding is harmful.”
The review authors were also specific in their conclusions: “Nevertheless, our systematic review highlights a clear and shared message delivered by all authors, which is that [ED boarding] may cause harm to patients waiting for an in-hospital bed. The authors emphasize the absolute necessity to implement efficient interventions to minimize [ED boarding].”
The U.K. study was able, however, to look at longer-term outcomes that other studies have not, including 30-day mortality, which Dr. Venkatesh said was especially important because most U.S. analyses only consider in-hospital mortality. “It's very possible that boarding may result in delayed diagnoses, poor care transitions, missed treatments, and other outcomes that may not manifest as harm during the immediate hospital stay, but will result in more severe illness later: a more severe heart attack, a more severe stroke, or other outcome causing death days later,” he said.
It would be difficult to conduct a similar U.S. study outside of large closed systems such as the Veterans Health Administration or Kaiser Permanente, and systems like those do not include EDs with the greatest strain and longest boarding times. “In those EDs, we just don't have the data to look at 30-day mortality among admitted patients or ready access to the same operational data streams to do the rigorous adjustments they did,” Dr. Venkatesh said. “But we should not need to do that; we should assume the picture is similar here. If you ask any chief quality officer at any U.S. hospital if they had a serious safety case in the prior year involving a patient boarding in the ED, I'm sure they would say yes. If you were to ask ED medical directors what the greatest latent safety risk is in their department, I'm sure most would say it's the unique form of crowding driven by such high levels of inpatient boarding.”
But boarding is largely out of the control of the department itself. “The entirety of the health care system is under unprecedented stress,” Dr. Venkatesh said. “I would argue that hospitals today are actually more dangerous than at the peak of the COVID-19 pandemic because then we were operating with more staff and more resilience than we have now. In our hospital, we actually are experiencing worse boarding times now than at the height of the pandemic. To put it in perspective, in our ED with 58 treatment spaces, we have needed to cram in well over 150 patients at times in the past few weeks alone.”
Most U.S. hospitals have average waiting times less than the magic four-hour window, but average waiting times of more than five hours are regularly reported at two of New York City's major EDs, three in Los Angeles, five in Chicago, and at least one ED in many other cities, including Austin, Dallas, El Paso, Fort Worth, Houston, Jacksonville, Nashville, Newark, Phoenix, San Diego, Seattle, Tucson, and Washington, DC. (Hospital Stats. https://bit.ly/3qUrdHc.)
“It certainly feels to me that the trend is that we are seeing more boarding, not less, both locally in the Boston area and elsewhere around the United States,” said Christopher Baugh, MD, the vice chair of clinical affairs for emergency medicine at Brigham and Women's Hospital and an associate professor of emergency medicine at Harvard Medical School. “The causes are multifactorial, but overall ED boarding is a symptom of a lack of hospital inpatient capacity. Obviously, the COVID-19 pandemic has strained our capacity, something hospitals everywhere are still dealing with, and recently it's typical to see enormous staffing challenges across multiple disciplines such as advanced practice providers, medical assistants, and nurses, so when beds are unoccupied, if they are not staffed, patients can't use them.
“Additionally, I'm hearing from my inpatient colleagues about patients who could be discharged to a rehabilitation facility or skilled nursing facility but don't have a place to go because many of the capacity and staffing issues affecting acute care hospitals are also affecting those facilities.”
Dr. Baugh suggested that ED leadership must advocate for sufficient staffing and resources to ensure that their patients are adequately cared for when there is a significant boarder population. “These are inpatients, even if they're physically in our department; we need to have the resources to care for them.”
Care at Brigham and Women's is typically transitioned to an inpatient team within one to two hours of making an inpatient bed request, even if the patient will remain physically in the ED. “When the inpatient team is assigned, we do a handoff, so that there isn't an extended period of time that ED providers are charged with taking care of that patient,” Dr. Baugh said. “This allows me to tell a patient that while upstairs is full, we will still transition your care to the same inpatient team that will be caring for you upstairs and it won't delay your diagnostics or treatment plan to have you physically stay here. The counterargument to this approach, of course, is that it takes some pressure off of the institution to move the patient out of the ED, institutionalizes boarding, and makes it more acceptable rather than saying this is dangerous and shouldn't ever happen.”
Larger systems' strategies to expand hospital capacity and reduce ED boarding will take a significant investment of time, money, and resources. One of these approaches is the hospital-at-home model, which institutions such as Mount Sinai Health System in New York, Presbyterian Healthcare Services in New Mexico, and Brigham and Women's are currently pursuing. Patients with manageable medical issues are discharged to their homes where a team of physicians, nurses, and other providers care for them daily as if they were in the hospital, tracking their progress between visits through continuous electronic monitoring, video chats, and texts.
Brigham and Women's launched its pilot in 2016, and it now serves about 300 patients a year. Two trials found improved costs, efficiency, and outcomes. (J Gen Intern Med. 2018;33:729; https://bit.ly/3RYfjrW; Ann Intern Med. 2020;172:77; https://bit.ly/3ds3OK7.)
“The proof of concept is there, but the scale is the question, and of course, there are unsettled related issues of health policy and reimbursement,” Dr. Baugh said. “But the great hope is that taking a certain percentage of inpatients off campus will create a capacity that will help ease this boarding issue. Larger systems that have the financial ability to pursue this are coming off the sidelines to bet on this idea; others are waiting to see how it plays out.”
Whatever the approach, Dr. Venkatesh said, the growing problem of extended ED boarding cannot be put off much longer. “We made this mistake with COVID-19 too. We said, ‘If we don't act, something bad will happen,’ when, in fact, the disaster was already happening. The same is true with boarding: Terrible outcomes are already occurring. For those of us working on the front lines, we can see it. We're not trying to prevent the car crash; the car has crashed. But if we don't fundamentally redesign the health care delivery system and change our assumptions, it's going to get much worse.”
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Ms. Shawis a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work atwww.writergina.com.