ED Boarding

Health care delivery related to the “boarding” of emergency department (ED) patients is a critical area of quality of care improvement for emergency medicine. Boarding is the process of holding patients in the ED for extended periods of time after an inpatient bed request is made (Asplin, et al., 2003). Boarding is widespread and interrelated to ED crowding. The Institute of Medicine (IOM) in 2006 reported that, ‘”boarding not only compromises the patient’s hospital experience, but adds to an already stressful work environment, enhancing the potential for errors, delays in treatment, and diminished quality of care’’ (Havens & Boroughs, 2006). This paper examines quality of care for boarded ED patients using Donabedian’s framework of structures,
Unstable patients have the priority to ED rooms. Typically, this means less critical boarded patients are often placed in hallways to make more ED rooms available for patients while they wait for admission to an inpatient unit. This setting subjects boarded patients to a disruptive and unpredictable environment. There are also inherent structural differences between the care provided to boarded patients compared to the care in inpatient units. First, emergency physicians (EPs) and nurses lack the proper skill set to manage boarded patients. Care in the ED focuses more on stabilization, disposition, and preliminary diagnosis than on inpatient observation and management (Hockberger, et al., 2005). Second, new patients act as a distraction and are higher priority for ED staff compared to boarded patients. This level of distraction increases potentially dangerous handoffs between EPs as compared to an inpatient service setting. According to the Institute of Medicine’s safety publication, To Err Is Human: Building a Safer Health System, emergency departments (EDs) are susceptible to “high error rates with serious consequences” (Havens & Boroughs, 2006). These structural differences may explain why boarded patients could experience compromised quality of
Distracted ED staff without the proper skill sets may lead to delays or errors in diagnosis and treatment, including delayed or omitted laboratory testing, procedures, and medication administration. In a study conducted by Penska, communication errors were the root cause in about 70% of cases when sentinel events occur (Pesanka, et al., 2009). Medication safety is a critical area to consider when examining process measures related to boarded ED patients. The risk of medication errors in ill boarded ED patients can lead to poor patient outcomes such as a decrease in blood pressure and oxygenation, heart arrhythmias, and multi-organ dysfunction (Richardson & Mountain, 2009). This serves as an example of process measures directly affecting the health outcomes of boarded ED