Emergency Department

It Is Better To Have Doctors Without Boarders Than Boarders Without Doctors

In the emergency room, boarders are patients who need to be admitted to the hospital but there are either no hospital beds to put them in or no doctors to admit them to. In Catholic doctrine, Purgatory is a holding place that souls go to in order to purge their sins before they go to heaven. From a patient’s viewpoint, being a boarder is a bit like being in purgatory – only it is disease rather than sins that need to be purged.

The problem with being a boarder is that the patient is not really an ER patient and not really a hospitalized patient but somewhere in between.  Sometimes, it is the ER physician who is overseeing the patient’s care – but the ER physician is really good at taking care of ER patients but not so experienced with managing admitted patients. Sometimes, it is the hospitalist who is overseeing the patient’s care – but the hospitalist spends most of his/her time at the nursing units and ICUs, not the ER so the patient is often “out of sight, out of mind”. It is not just the doctors, but also the nurses – the usual activities of an ER nurse are very different than the usual activities of an inpatient unit nurse.

A study in the Annals of Emergency Medicine found that boarders are more likely to have delays in order completion or orders missed altogether compared to patients admitted to an inpatient nursing unit. A study in Academic Emergency Medicine found that boarders have a higher mortality rate than non-boarders. A study in Critical Care Medicine found that boarders have a longer hospital length of stay than non-boarders. A study in Academic Emergency Medicine found that boarders have a lower patient satisfaction than non-boarders. All-in-all, boarding is bad.

So, if boarding is so bad, why is it so prevalent in our country’s hospitals? As usual, there is not one single reason but some of them include:

  1. Increased demand on hospitals to achieve higher levels of operational efficiency. In order to solve the boarding problem, a hospital has to have excess capacity and excess capacity often translates to higher costs. You have to have more rooms, more nurses, more pharmacists available on any given day in order to accommodate the occasional surge in patient admissions. And all of those extra rooms, nurses, and pharmacists cost money – a lot of money. A hospital administrator cannot afford to run the hospital at 60% capacity most of the time in order to accommodate the occasional time that it is at 100% capacity.
  2. Inpatient census caps on residents. At many hospitals (particularly academic hospitals), residents historically did most of the admissions to the hospital. Beginning in the late 1980’s and stimulated by the Libby Zion case, the ACGME began to place duty hour restrictions on residents (how many hours they could work per week) and census caps restrictions on residents (how many patients they could take care of). As a result, teaching hospitals were no longer able to accommodate census surges using resident coverage. Today, hospitals that exceed the ACGME-required census caps run the risk of losing their ACGME accreditation and this can be a lethal blow to the hospital’s residency program. Therefore, at teaching hospitals, admissions can back up in the emergency department while waiting for a teaching service to have census capacity, even if there are empty beds on the inpatient nursing units.
  3. Hospitalist census caps. 20 years ago, there was no such thing as a census cap on an inpatient medical service. A physician took care of all of the patients admitted to his/her care and if there were a lot of patients, the doctor just stayed late into the night caring for them. With the emergence of hospitalists as the dominant model of inpatient care, things have changed. Hospitalist work shifts and there is a finite number of patients that they can see during one shift. Hospitalists are also tasked with meeting certain quality goals, such as keeping a low length-of-stay and getting patients discharged early in the day. In order to meet these quality of care goals, hospitalists need to maintain a manageable number of patients under their care. Furthermore, today’s hospitalists trained in an era of ACGME-mandated census caps for residents and those census cap expectations have carried over into their own practice. Hospitals compete with each other for the best hospitalists and if a hospital regularly exceeds the expected inpatient census per hospitalist, then those hospitalists are going to leave to go practice at a competing hospital.

So, what are the solutions? It would be easy if a hospital could do just one thing and solve the boarder problem in a cost-effective manner. But as with most issues involving process improvement, it takes a multi-step approach:

  1. Create flexible inpatient capacity. Ideally, a hospital should have at least one nursing unit that can be opened and closed as needed in order to meet inpatient demand. This requires not only the physical beds but also requires a pool of nurses who can be brought in on-demand to staff those beds during times of need. Flexible staffing often requires paying those on-demand nurses a little more but it can be worth it if it results in fewer boarders.
  2. Analyze daily and weekly ER admission trends. Mondays and the day after holidays tend to have the highest number of patients admitted through the emergency department. Anticipating this weekly surge in admissions with appropriate staffing can allow for the hospital to flex up in anticipation of more admissions. This may require scheduling more nurses or an additional hospitalist on those days.
  3. Analyze daily and weekly surgical admission trends. Certain types of surgeries result in hospital admissions, for example, coronary artery bypass operations and joint replacement operations. If surgeons who do these types of operations have their operating room time all clustered on a single day of the week, then there will be a surge in admissions on that day. By strategically scheduling these surgeons’ operating days, the hospital can control the daily number of admissions, thus spreading out the demand for inpatient beds.
  4. Encourage early morning discharges. Hospitalist and resident census caps are fixed but as soon as that doctor discharges one patient, they can take another admission and stay within their cap. By discharging some patients earlier in the day, there will be both bed and physician capacity to admit patients from the ED earlier in the day.
  5. Educate the hospital CFO. Creating flexible inpatient capacity to avoid boarding patients in the ED costs money and on the surface, it can appear that the hospital’s cost are going up. However if by spending money to accommodate these admissions and avoid ER boarding, the hospital is able to reduce length of stay, improve mortality rates, and reduce emergency department diversion hours, then the overall financial metrics of cost per hospital admission, etc. can actually improve.

Human disease does not occur with precise predictability and so the hospital has to be creative in devising strategies to accommodate surges in inpatient demand. The hospital’s goal is to be able to have enough doctors so as to prevent ER boarders. You want to always avoid having boarders without doctors.

April 15, 2018

By James Allen, MD

I am a Professor Emeritus of Internal Medicine at the Ohio State University and former Medical Director of Ohio State University East Hospital