Just Say No to Boarding in the Emergency Department | Best Practices for Elimination the Boarding Burden

Boarding patients in the emergency department has a negative effect on patient satisfaction and increases the risk of adverse events and poor clinical outcomes.

In fact, in one study1 of more than 41,000 admissions from the ED, mortality increased with boarding time from 2.5 percent in patients boarded less than two hours to 4.5 percent in patients boarded 12 hours or more. Length of stay also increased with boarding time from 5.6 days for those who stayed in the ED less than 2 hours to 8.7 days for those who were boarded for more than 24 hours.

Then there are the negative downstream effects of boarding, including inability to treat newly arriving patients, longer cycle times for existing ED patients and poor perception of quality and confidentiality by boarded patients. A recent Studer Group survey of 635 ED directors in 48 states also found that boarding puts staff and provider engagement at risk by creating a more stressful work environment, lowering moral, reducing job satisfaction and increasing nursing turnover.

In addition, The Joint Commission has made boarding part of its survey process because it's a patient safety issue. It expects to see a boarding action plan that measures the extent of the problem and tracks improvement. With the stakes so high, can we afford to not address this issue?

7 Ways to Solve the Boarding Challenge

1. Make Efficient Throughput Everybody's Job.

In our experience, most hospitals feel they already have a robust throughput strategy in place. But in practice, when we do a deep dive, we often find that many organizations lack a holistic approach to the problem. There's often a perception that throughput is an ED problem, rather than a hospital-wide one. In most cases, these are inpatients waiting to be admitted. In fact, we should probably call them "inpatient holds boarding in the ED." Changing this perception starts with the CEO and board of directors at the hospital.

Studies show a higher risk of mortality for patients who are boarded in the ED. While ED nurses are skilled at inpatient care, their focus must be on emergent patients. Plus, inpatient documentation systems and methods differ from those in the ED so it's always better to board a patient on the floor or hallway of the hospital.

The best way to identify and address barriers to throughput is to bring all the stakeholders together at a hospital throughput committee and hold them accountable by aligning individual goals and tracking performance metrics in a dashboard.

An effective committee meets monthly and typically convenes 12 to 15 individuals who can best drive process improvement and remove barriers for admitting patients quickly. It's an interdisciplinary team including hospitalists, leaders from the ED and inpatient leaders from critical care, telemetry and med-surg.

2. Involve Physician Leaders.

By participating in process improvement, physician leaders can lend their weight by helping the hospital prioritize the ED boarding burden. Connect the dots for physicians by explaining that delays in patients being admitted is not in the best interest of patients. Explain that you need their help to change patient routing to expedite discharge. Ask hospitalists what metrics would be helpful for the group to monitor. (An example: One hospitalist we know tracks the time from when the discharge order is written to actual discharge as a performance metric.)

Physician involvement also demonstrates support for nurses who can benefit from tools, time and expertise. For instance, when physicians are involved in discharge planning, nurses can better execute the discharge planning process and become proactive instead of reactive. Patient discharge and follow-up education is clearer and more consistent resulting in better patient adherence to physician orders and higher quality clinical outcomes.

3. Use a No-delay Nurse Report.

No-delay nurse reports reduce time from admit orders to arrival on inpatient units, decrease the potential for handoff errors (because they ensure the ED and inpatient nurses have the same information) and increase patients' perception of care due to timely transfer of care.

A sample process might look like this: After the order is written and a request for a bed is made, the ED nurse opens a "transfer of care" report, which is accessible to the floor nurse. The ED nurse then awaits the patient bed assignment (by monitoring the tracking board).

Fifteen minutes after the bed has been assigned, either the unit clerk calls down to the ED to accept the patient or the accepting inpatient primary nurse or charge nurse calls to ask questions. In either case, the ED patient is transferred within 15 minutes of a bed becoming available.

4. Adjust Workflow.

Frequently, inpatients boarded in the ED are the last patients that hospitalists, intensivists and consultants round on. By rounding on them first in the morning instead, patients who need to be downgraded or discharged are identified earlier for actions later that same day. This is also a safety issue as the hospitalist may detect a change in condition requiring intervention or an upgrade.

In the same way, by rounding first on patients that were identified the prior day as potential discharges, the hospital creates more capacity early in the day. Adjusting workflow can have a huge positive impact on risk, safety, length of stay and patient satisfaction.

5. Set a Viable Surge Policy.

The goal of a surge policy is to create a proactive, early response system that decompresses busy times in the ED instead of operating in disaster mode. While most hospitals have such a policy, they don't typically utilize it appropriately (or early enough) and operate most of the time in disaster mode instead.

A good surge policy is realistic and escalates gradually in a structured way that initiates a defined response from other departments and inpatient leaders. A color-coded system where green is good, yellow requires a heightened response, orange requires a greater response is useful. Then the ED doesn't have to operate in "red" or "black" mode.

While it's true that driving the implementation of a new surge policy can be labor-intensive in the beginning, it pays big dividends over time. As staff and providers become accustomed to how to respond, time drops dramatically.

6. Ask Inpatient Nurse Managers to Round on Boarders.

Before initiating nurse manager rounding on boarded patients, explain the "why." Then emphasize the "what" and "how. Inpatient leader rounding ensures safety (e.g., a safe handoff and safe acceptance of inpatient) and quality (e.g., improved morbidity and mortality.)

By connecting inpatient leaders with boarders, we also establish ownership for the transition and build trust. Frequency of rounding is tied to the hospital surge plan with leader guidance and instruction for inpatient units and defined roles and expectations for staff and physicians at tiered surge levels.

7. Streamline Discharge.

It's rare that there are truly no beds available in a hospital. What's more common is that delays in the inpatient discharge process are to blame for unavailable beds. Sometimes the best intentions can have unintended negative consequences. In one organization, for example, the pharmacy delivered a two-week supply of medications to patients before they were discharged. It was an excellent process that ensured that medications were filled promptly.

However, while patients waited, their rooms remained unavailable, increasing room turnaround time. By setting up a pharmacy reception area, however, this organization was able to realize the pharmacy benefit and speed up room availability.

A common barrier to inpatient discharge is the time it takes to complete the electronic medical record. Ask: What can we do to minimize that barrier? For example, is it possible to chart ahead of time? Even if a nurse doesn't know exactly when a patient will be discharged, he or she likely knows if a patient will be discharged soon. In such cases, it's possible to begin working on discharge orders 24 hours ahead of time rather than at the moment of discharge.

Addressing boarding in the ED requires an enterprise-wide response; it's not just an emergency medicine problem. Executives play a critical role in goal setting, accountability and role modeling communication and teamwork among stakeholders.


1 Singer, AJ, Thode, Jr. H, et al. “The Association Between Length of Emergency Department Boarding and Mortality.” Soc for Ac Em Medicine. 2011.

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  • Angie Esbenshade

    Angie Esbenshade, RN, MSN, MBA, NE-BC

  • Sachin Shah

    Sachin Shah, MD, MBA, FAAEM

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