Inpatient Boarding Definitions and Mitigation Strategies: A Cross-Sectional Survey of Academic Emergency Departments in the United States

Abstract

Objective:

Conceptually, inpatient boarding is a result in the delay of admitting patients from the Emergency Department (ED) to inpatient units, but there is no consistent definition across academic EDs. The purpose of this study was to evaluate the definition of boarding across academic EDs, and to identify mitigation strategies used by EDs to alleviate crowd management.

Methods:

This was a cross-sectional survey of boarding-related questions (i.e., boarding definitions and practices) that were embedded into the annual benchmarking survey conducted by the Academy of Academic Administrators of Emergency Medicine and the Association of Academic Chairs of Emergency Medicine. Results were descriptively assessed and tabulated.

Results:

Of the 130 eligible institutions, 68 participated in the survey. Approximately 70% of institutions reported starting the boarding clock at the time of ED admission, while 19% reported that the clock started with the completion of inpatient orders. Approximately 35% of institutions considered patients boarded within 2 hours, while 34% considered patients boarded >4 hours after admission decision. In response to ED overcrowding brought on by inpatient boarding, 35% reported using hallway beds for patient care. Surge capacity measures reported included having a high census/surge capacity plan (81%), going on ambulance diversion (54%), and institutional use of a discharge lounge (49%).

Conclusions:

We found that definitions for boarding varied widely. Inpatient boarding has serious consequences to patient care and well-being, suggesting the need for standardized definitions to describe inpatient boarding.

INTRODUCTION

Inpatient boarding, the delay in admitting patients from the Emergency Department (ED) to an inpatient unit, has been shown to have negative impacts on the morbidity and mortality of patients under evaluation in the ED.[1] [2] Both the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) have attempted to introduce metrics to measure the values and impact of inpatient boarding. In 2014, JCAHO released standards that required hospitals to measure and report on inpatient boarding but did not provide measurable targets for compliance; JCAHO did suggest that best boarding practices would indicate that a patient should wait a maximum time of four hours before being placed into an inpatient unit.[3] CMS initially provided an ED metric (ED-2) in 2016, which recorded the median time from decision to admit an ED patient to their actual departure.[4] However, this metric was part of a voluntary reporting requirement and was ultimately sunset in 2021.[5] In order to understand the current definitions used, and subsequently the impact on patients, we need to identify the definitions employed for inpatient boarding and local mitigation strategies utilized by healthcare systems facing this issue.

We aimed to investigate the various definitions of boarding used by EDs in academic medical centers (AMCs) and to explore the various mitigation strategies employed by health systems to offset the negative outcomes associated with boarding. By assessing these data, we hope to advance the need for an accepted definition of boarding and boarding time so that future innovations and trials can be used to objectively measure the possible benefits of the multitude of mitigating strategies employed by AMCs.

METHODS

Setting, Study Sample, and Design

The Academy of Administrators in Academic Emergency Medicine (AAAEM) and the Association of Academic Chairs of Emergency Medicine (AACEM) jointly established a benchmarking survey administered annually to allopathic, academic departments and divisions of EM.[6, 7] Eligible programs included those with a full academic department in Liaison Committee on Medical Education accredited medical schools; divisions or sections of a different department in a medical school that hosts an Accreditation Council for Graduate Medical accredited EM residency program; or a hospital-based department, division, or section that is affiliated with a medical school and hosts an accredited EM residency program.[6, 8] The original survey examines clinical care, education, research, faculty effort, and compensation, and is administered annually. For this study, we coordinated with AAAEM/AACEM to incorporate additional survey questions that specifically identified boarding practices and surge capacity measures into the annual, cross-sectional survey for 2022. Surveys were given to EM administrators to fill out at each site. For sites that participated in the annual benchmark survey but did not answer the boarding-specific questions, we sent these survey questions through the Research Electronic Data Capture (REDCap) data management platform to ED chairs (n=21). This study was deemed as not human subjects research by our Institutional Review Board and is reported in accordance with the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines.[9]

Boarding Metrics and Surge Capacity Measures

We incorporated questions into the existing survey that identified boarding definitions, and use of hallway beds and discharge lounges as they pertain to boarding, and surge capacity measures. For boarding, we asked: (1) When does your institution start the boarding clock; and (2) At what point of time is a patient considered boarding in your department. For hallway beds, we asked: (1) Does your hospital board patients in inpatient unit hallways; (2) If you use hallway beds, describe the majority of patients for whom they are used. For surge capacity measures, we asked: (1) Does your hospital have an ED specific high census/surge capacity plan; (2) Does your hospital use a discharge lounge; (3) Does your hospital go on diversion in response to ED overcrowding, (4) During fiscal year 2019, how many times did your hospital cancel or delay elective surgery in response to hospital overcrowding. We additionally asked the open-ended question: Please describe any measures that your institution has enacted to help alleviate boarding in the ED.

Data Analysis

To assess potential non-response bias of participating and non-participating EDs for the portion of the survey regarding boarding, we categorized those who completed the entire survey and those who did not. We assessed differences in hospital and aggregate patient-level characteristics captured by the survey. All differences were calculated as Cohen d or h statistics to assess meaningful differences and represent a standardized mean difference in proportions (categorical variables) and means (continuous variables). For the main boarding survey questions, we evaluated the frequency and distribution of each boarding and surge capacity question. For the open-ended question (measures to alleviate ED boarding), we report the descriptive measures and strategies used.

RESULTS

Of the 130 eligible institutions, 83 completed the annual benchmark survey (64%) and 68 EDs (52%) responded to our boarding questions. Among EDs that completed the benchmark survey, effect size estimates demonstrated minor differences between those that did and did not answer the boarding questions such as the distribution of patient populations or regional variation in participation (Table 1).

Table 1.

Comparison of Participating and Non-Participating EDs for Boarding Survey Questions among all AAAEM-AACEM Benchmarking Survey Respondents

Benchmark Survey Measure	Includeda n=68		Not Includeda n=15		Effect Sizeb
Hospital Characteristics
Region (n, %)
Midwest	14	20.6	2	13.3	0.19
Northeast	25	36.8	7	46.7	0.20
South	18	26.5	4	26.7	<0.01
West	11	16.2	2	13.3	0.08
Funding (n, %)
Private	36	52.9	9	60.0	0.14
State	31	45.6	4	26.7	0.40
Trauma Center Level (n, %)
I	45	66.2	9	60.0	0.13
II	6	8.8	1	6.7	0.08
III	1	1.5	0	0.0	0.24
N/A	9	13.2	4	26.7	0.34
Has Separate Pediatric Beds (n, %)	33	48.5	5	33.3	0.07
Has Staffed Pediatric Beds (n, %)	29	42.6	5	33.3	0.06
Licensed Hospital Beds (mean, SD)	657	286.6	670	381.0	0.00
Staffed Hospital Beds (mean, SD)	625	270.4	564	382.0	0.02
Hospital Admissions (mean, SD)	27,995	12,313.7	24,349	15,132.0	0.03
Total ED Treatment Space (mean, SD)	61	31.0	65	19.0	0.02
Disposition (mean, SD)
AMA	816	591.2	1,132	1,254.3	0.05
ED Discharge	36,058	14,295.8	38,148	12,845.6	0.02
ED Admissions	15,942	9,385.7	13,536	6,466.9	0.03
ED Hospital Observations	3,475	3,226.3	4,378	2,360.5	0.03
ED Transfers	2,421	11,546.4	1,022	1,368.5	0.01
Patient Characteristics (mean, SD)
% Patients age 65+	11	11.4	24	3.4	0.14
% Pediatric Visits	28	6.7	7	7.9	0.33
% Self Pay	29	11.6	7	12.3	0.21
% Medicare	27	11.0	32	6.9	0.05
% Medicaid	21	6.5	34	9.4	0.19
% Managed Care	5	6.6	23	14.5	0.24

Abbreviations: ED: Emergency Department; AAAEM: Academy of Academic Administrators of Emergency Medicine; AACEM: Association of Academic Chairs of Emergency Medicine; SD: standard deviation; AMA: Patient left against medical advice

^aEDs included in the study represent those that responded to the boarding questions, while those not included include those that completed the survey but did not respond to the boarding questions.

^bAll differences were calculated as Cohen d or h statistics to assess meaningful differences and represent a standardized mean difference in proportions for categorical variables and means for continuous variables.

Among institutions that answered the boarding questions, there were differences regarding when they started the boarding clock (Table 2); 69% started at the ED decision to admit, followed by 19% that started when inpatient orders were completed. Boarding definitions also varied: 35% were considered boarding within two hours of the admission decision, 29% between 2–4 hours, and 24% after more than four hours following admission. Approximately 28% boarded patients physically in inpatient hallway beds during a surge only, while 7% used them routinely. Among boarded patients placed in ED hallway beds, 19% were non-mental health patients, followed by 10% of new ED patients, and 6% who were awaiting discharge.

Table 2.

Results of Boarding and Surge Capacity Management in Academic EDs

Question	N	%
When does your institution start the boarding clock?
Consultant agrees to admit	5	7.4
ED decision to admit	47	69.1
Inpatient orders completed	13	19.1
It differs by service	1	1.5
Unknown	2	2.9
At what point of time is a patient considered boarding in your department?
Within 2 hours after admission	24	35.3
Between 2–4 hours after admission	20	29.4
>4 hours after admission	16	23.5
Unknown	8	11.8
Does your hospital board patients in inpatient unit hallways?
Yes – only during a surge	19	27.9
Yes – routinely	5	7.4
No	32	47.1
Unknown	10	14.7
If you use hallway beds, the majority of patients who use them are:
New ED patients	7	10.3
Mental health patients undergoing care/admitted	1	1.5
Non-Mental Health patients undergoing care/admitted	13	19.1
Patients awaiting discharge	4	5.9
Even combination of all patient groups	15	22.1
Unknown	28	41.2
Does your hospital have an ED specific high census/surge capacity plan?
Yes	55	80.9
No	10	14.7
Unknown	3	4.4
Does your hospital use a discharge lounge?
Yes	33	48.5
No	33	48.5
Unknown	2	2.9
Does your hospital go on diversion in response to ED overcrowding?
Yes	37	54.4
No	29	42.6
Unknown	2	2.9
During fiscal year 2019, how many times did your hospital cancel or delay elective surgery in response to hospital overcrowding?
Never	22	32.4
Rarely	15	22.1
1–2 times per month	0	0.0
3–4 times per month	0	0.0
5+ times per month	6	8.8
Unknown	25	36.8

Abbreviations: ED: Emergency Department

For boarding mitigation strategies, 81% of EDs reported having a high census or surge plan, 49% utilized a discharge lounge, and 54% went on diversion in response to ED overcrowding. Delaying or canceling elective surgeries was not a widely accepted mitigation strategy; in 2019, 55% reported rarely or never canceling or delaying elective surgeries due to overcrowding (Table 2).

Several strategies were reported to alleviated boarding in the ED, including: Identifying other areas in the hospital for boarding patients, early inpatient discharges and the use of a discharge lounge, engagement with case management/social work for early outpatient follow-up, cancelling elective surgeries, use of ED physician to manage transfer calls, extending operational hours of operating rooms, using non-clinical staff nursing staff to assist with transport, transferring ED patients and inpatients back to their home institution after need for tertiary care completed and the use of inpatient teams to manage ED boarders (Table 3).

Table 3.

Select Measures Reported to Alleviate Boarding in the ED

1.	Identify other areas in hospital for boarding (inpatient hallways, PACU, pre-operative areas)
2.	Early inpatient unit discharges
3.	Engagement with case management/social work/PCPs for early follow-up to avoid admission
4.	Use of discharge lounge
5.	Cancelling elective surgeries
6.	Use of ED physician to manage transfer calls
7.	Extending operational hours of operating rooms and ancillary hospital services
8.	Use of non-clinical nursing staff to assist with transport and other clinical duties
9.	Transfer ED patients and inpatients back to home institution after need for tertiary care complete
10.	Use of inpatient teams to manage ED boarders

Abbreviations: ED: Emergency Department; PACU: Post Anesthesia Care Unit; PCP: primary care physician

DISCUSSION

The AAEM-AACEM benchmarking survey provides an annual snapshot of academic EDs. The added boarding questions were intended to provide insight into how AMCs define inpatient boarding and offer mitigating strategies to alleviate the problem. Our results show that there is a wide variation in both boarding definitions and in individual hospital practices to combat boarding issues.

The question of when an admitted patient becomes a ‘boarder’ is of critical importance. When the decision to admit a patient has been declared, is that patient automatically a boarding patient? Does a certain period of time need to pass before he/she is considered in boarding status? If so, what is an appropriate period of time? These questions become important in light of hospitals’ development and assessment of the effectiveness of mitigating strategies. Our survey shows that the majority of hospitals (69.1%) start the boarding clock when the ED makes the decision to admit the patient. However, 19.1% consider the boarding clock to start only after the inpatient team has written inpatient orders, which is often expressed by a significant time difference. Different academic EDs have also reported a wide variety of time lengths from when the clock starts to when a patient is considered boarding

While there have been some efforts to standardize ED boarding definitions, there are no nationally defined standards that all hospitals use. In 2014, the Joint Commission recommended a national maximum boarding time of four hours; however, this has not been imposed as a requirement for accreditation.[10] The National Hospital Ambulatory Medical Care Survey asks the question if “Admitted patient were ever boarded 2 hours or more in ED or observation while waiting for inpatient bed.”[11] CMS released in 2016, ED-2, which recorded the median time from the decision to admit an ED patient to their physical departure from the ED.[4] Unfortunately, this measure was terminated in 2021. The Emergency Department Benchmarking Alliance defines boarding as the admission decision to departure interval.[5, 12] The creation of one recognized standard definition of inpatient boarding would allow for accurate reporting of this phenomenon, research of effective strategies to improve outcomes, and the ability to advocate for the best interests of patients.

Our survey also assessed what individual hospitals are doing to mitigate the current ED boarding issue. One mitigation strategy of using inpatient hallways to board patients has been much discussed in the EM community. Our study showed that only 7% of hospitals are routinely using inpatient unit hallways to board patients routinely and 28% will use during a surge. Tabriz and colleagues performed a semi-structured interview study to evaluate decision-making in this process;[13] they concluded that the key determinants of success included collaborating with inpatient nursing, achieving consensus about criteria for activation, complying with external regulations and policies, modifying the electronic medical record, and gaining hospital leaders’ support.

Our study also demonstrated varying practices in surge capacity plans for the ED and use of hospital discharge lounges. Hospital discharge lounges can provide a space for patients to move out of their inpatient room in the hopes of placing new patients more promptly, and has been evaluated regarding the impact on ED boarding.[14] Franklin and colleagues concluded that discharge lounges are widely encouraged to help clear inpatient beds more timely endorsed, but that there is limited available evidence regarding the best ways to utilize them. One strategy that has been shown to be effective is the delay or cancellation of elective surgeries; however, few AMCs are adopting this procedure, most likely due to economic reasons.[15]

This study had several limitations. While the overall response rate for the boarding-related questions reached only 52%, the departments that completed the survey represent a wide variety of academic EM programs. Thus, we believe the data can be safely extrapolated. Given that our survey was provided to EM administrators, it is possible that the results suffered from selection bias due to the vested interest Departments of EM have in finding solutions to the problem of inpatient boarding. Finally, our survey covered a wide array of mitigating strategies with which the survey respondents may not be familiar, and those reported have been summarized but may not have been standardized approaches that we could not quantify further.

CONCLUSIONS

Our investigation revealed that academic EM programs utilize a wide variety of inpatient boarding definitions and that no consistent approaches are used to improve inpatient boarding in the ED. Having a uniform definition that is employed by all stakeholders is necessary to define and measure this topic and to study the impact of different interventions. Future research should focus on determining the boarding time increments considered safe and acceptable prior to patient transport to inpatient units, and the establishment of time standards for the implementation of effective mitigating strategies.