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Boarders and Emergency Department Flow

by Bob Patton on March 15, 2018 at 8:22 AM

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It is a story heard over and over again from emergency department (ED) physicians, a story involving boarders (patients occupying beds while awaiting transport to the floor):

"By mid-afternoon every Monday and Tuesday, we have five patients in beds that have been ready for hospital admission for hours... and it is usually several more hours before their transport will begin! In the meantime, those occupied beds are making it impossible for us to keep the normal flow through the department, and our waiting room backs up horribly. We spend the whole evening working through the backlog, and our wait times are far from our goal as a result. The hospital is telling us we need more provider coverage, but that is not the problem." 

It is an old story and is rooted in the deep differences in culture, schedule and flow patterns between the emergency department and the hospital. When a hospital patient is going to be discharged on a given day, there is no immediate and visible need to rush that process. If delayed and the patient doesn't leave until mid-afternoon, what's the worry? The floor staff members do not see patients waiting for rooms. There are no patients waiting on beds in the hallways. Thus, the pace of process on the hospital floor is justifiably un-rushed. Patient stays are measured in days.

In contrast, the ED measures a patient’s length of stay (LOS) in hours. EDs are charged to stay under target LOS values and are judged by whether or not they meet those goals. Each bed gets cleaned and prepared for a new patient multiple times a day. Any bed effectively taken out of circulation for hours during the busiest time of day has a critical impact on the departmental flow.

In an effort to resolve the flow problems caused by these long-occupied beds, some EDs resort to moving patients onto beds in hallways while they are awaiting transportation to the floor. Due to cultural differences and lack of understanding, other departments are horrified at this practice and call it barbaric. After all, floor nurses refuse to have beds in their hallways. A contentious relationship can hence develop between the ED and the floor. 

The irony is that those making the claims of barbarism are also part of the complete system—the hospital in totality—that is causing the situation, and it is likely that their own departments have practices that are unwittingly contributing to the problem. Even more ironic is that study after study has proven that outcomes for patients on a bed in a hallway in the emergency department are significantly worse than outcomes for that same patient on a bed in a floor hallway. This is not the fault of the emergency department; it is simply not what they are designed for either in their construction or processes. Once the decision to admit has been made, the optimal care environment for that patient is the one that exists up on the hospital floor. 

Finding the Best Solution 

So what is the solution to this complex problem? One approach is to immediately move the admitted patient to the floor regardless of whether or not the room is already available. Unfortunately, the cultural barriers against such change are monumental. In large complex enterprises, regardless of industry, cultural change can only be affected from the top down. 

In several published case studies, the hospital administrator decided to take a hard line at forcing the necessary systemic and cultural changes. They decreed that there would be no patients on beds in hallways in the emergency department. Those patients will be immediately moved to the floor to await their room. The results of events in the ED on those busy days now become glaringly visible to the floor staff who then become participants in the solution to the problem. This can help to drive the cultural change. Some hospitals publish the emergency department metrics system-wide to contribute to this "one system" culture and enable all departments to participate in eventual successes.

All patients benefit as well. The patient waiting for a room gets the much more appropriately designed care of the floor staff and probably gets a bed quicker as morning processes are tightened up to make the daily discharges happen earlier. Patients spend less time in the ED waiting room as beds become available sooner and departmental flow is maintained. 

In full disclosure, this is only one issue that can cause significant flow problems in the ED. Lab turn-around times, nursing shortfalls and even problems with housekeeping related to the rate at which an empty bed can be made ready for the next patient at critical times of the day can all result in flow bottlenecks. The ED is an exceptionally complex system and performance often suffers from "death by a thousand cuts." No one change will magically make everything work perfectly.  

Never-the-less, given the patient outcomes, the research and the ubiquity of this problem, it is clear that boarders are one of the primary components of ED flow issues. So why is it that more hospitals have not enacted similar changes to attack the problem? The truth is that cultural change is initially painful. Also, modeling tools that can simulate the problem and aid in testing the efficacy of potential changes are not readily available.

 At Intermedix, as part of our growing analytics offerings, we are constantly exploring solutions that will help EDs with significant flow problems gain awareness and insight into the components of the problem. Our goal is to give providers the tools and information necessary to more fully understand their world and help drive positive change, and we believe that descriptive, predictive and prescriptive analytics will continue to give us solutions to address healthcare challenges.

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This post was written by Bob Patton

Bob Patton is Director of IT Applications at Intermedix. He has more than 20 years of experience in software development, nearly a decade of which has been spent in the healthcare industry. He has a passion for technology and the people it helps. Bob earned his bachelor’s degree in physics from Texas A&M University and holds a PhD in mathematics from the University of Texas at Austin.

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