FOR YEARS, emergency physicians have complained about patients being boarded in the ED, waiting hours or days for a transfer or an inpatient bed. But according to emergency physician Gregg Miller, MD, ED boarding is now the worst he’s seen in his 15 years of practice.
“It is absolutely a crisis,” says Dr. Miller, chief medical officer of Vituity, a physician-led multispecialty partnership at more than 500 hospital locations nationwide. In November 2022, the American College of Emergency Physicians, along with more than 30 other medical associations and advocacy groups, sent a letter to the White House, detailing the burden and dangers of ED boarding, including deaths taking place among boarded patients.
“Boarding has become its own public health emergency,” the authors stated, calling for the administration to convene a health care summit to determine immediate and long-term solutions. Since that letter went out last November, however, the problem of ED boarding by all accounts has only gotten worse.
“The post-acute logjam backs up flow all the way through inpatient units down to the ED.”
Gregg Miller, MD
Vituity
EDs with 20 beds now routinely have 40 boarders and a packed waiting room. ICUs with high nursing turnover have cut their number of critical care beds, while shortages of floor nurses have led to closed beds, if not closed units. EMS short-staffing means that transfers—already delayed because of capacity problems in receiving hospitals—take even longer, and states report a precipitous drop in the number of available post-acute beds, due to lost staff.
“That post-acute logjam,” says Dr. Miller, “backs up flow all the way through inpatient units down to the ED and out to the ED waiting room—and in some cases, out to the parking lot.”
That logjam also puts hospitalists in the ED, providing hallway care. Hospitalist groups have created care pathways to incorporate boarders into their daily rounds, while hospital leadership is assigning ancillary services—phlebotomists, physical therapists—to EDs to take some of the load off ED staff.
Floor and even ICU nurses now sometimes float to the ED for boarders, at least when staffing permits. And IT departments have worked to bridge the ED and the inpatient EHRs, giving emergency department staff access to inpatient orders, prescriptions, meal plans—all to support a new status quo.
“We realized very early on that health care staffing problems aren’t going away,” says hospitalist Bryan Harris, MD, chief medical officer of St. Charles Redmond Hospital in Redmond, Ore. “What we call ‘workarounds’ for ED boarding is now business as usual.”
Record-high volumes
In some hospitals, hospitalists didn’t begin to manage ED boarders before covid surges. But now, as the pandemic continues to wind down in hospitals, ED boarding appears to be getting worse.
“This January, we had the highest volumes we’ve ever seen.”
James Leyhane, MD
Crouse Hospital
Take Crouse Hospital in Syracuse, N.Y. Hospitalist medical director James Leyhane, MD, says that in 2017, the average daily census for his group was between 110 and 120. But “we haven’t been below 170 in two years,” Dr. Leyhane says, “and this January, we had the highest volumes we’ve ever seen with a huge influx of medical patients.” Daily hospitalist census figures shot up into the 200s, and ED boarders were a big slice of that outsized census.
His own hospital hasn’t been desperately short-staffed, nor has it closed inpatient units due to nursing shortages. But other local hospitals have, driving more patients to the Crouse ED. Another factor: Outlying hospitals have seen the few subspecialists they have either retire or cut back hours, reducing specialty capacity in those hospitals and driving more transfers into Syracuse.
At Jefferson Regional Medical Center in Pine Bluff, Ark., hospitalist medical director Naznin Jamal, MD, notes that her hospital had some of its highest numbers of ED boarders between November 2022 and January 2023—months when the hospital’s covid population had dwindled
“We’ve had quite a few patients with hypoxemia and respiratory failure secondary to other viruses such as influenza,” Dr. Jamal says. “We’ve also seen severe rhinovirus and metapneumovirus cases as well.”
“No floor nurses are going down to the ED. We don’t have enough to spare.”
Naznin Jamal, MD
Jefferson Regional Medical Center
With hospitals throughout her entire state often at capacity, many patients being boarded in her ED are awaiting transfer. The collaborative management agreement Dr. Jamal’s group worked out with the ED says that when the ED can’t successfully arrange a transfer within six hours, “hospitalists come down to the ED to do an outpatient consult on that patient, and we enter orders,” she explains.
As consultants, hospitalists continue to round on ED boarders every day until a bed is found either in her own hospital or elsewhere. (Most boarded patients obtain a bed within 12 to 24 hours.) As for nursing care, the ED nurses are treating the boarders. “No floor nurses are going down to the ED,” says Dr. Jamal. “We don’t have enough to spare from our admitted patients.”
Hospitalists take over care
At Kettering Health in Kettering, Ohio, Ashlee Ames, MD, medical director of the hospitalist program that covers three network hospitals, says that nursing leadership assigns some med-surg nurses from the floors to ED boarders, at least during the day. At night, the boarders are often tended by ED nurses.
As ED boarding moves on to crisis level, hospitalists are moving into hallway medicine. For more coverage: Should you board patients in inpatient hallways? A look at pros and cons.
Most patients being boarded at Kettering Health are waiting for an inpatient or an observation bed, not a transfer—and many are assigned to the hospitalist service. The hospitalist advanced practice providers (APPs) who staff the observation unit round on boarded patients waiting for an observation bed, while boarded inpatients are admitted to the physicians and distributed among day-shift teams.
“When they come in at 7 a.m., we ask hospitalists to at least look at those patients’ charts, make sure their orders have been released and see if they’re getting their meds and testing,” Dr. Ames says. “If they think patients may appear more ill from chart review, we ask them to lay eyes on them or to talk to the nurse assigned to those patients to make sure things get moving for the day and that patients don’t need urgent interventions.” Typically, hospitalists first do morning discharges and round on high-acuity patients on the floors before rounding on ED boarders.
Possible discharges?
Dr. Harris in Oregon says that the hospitalists in his group likewise “admit” all boarders waiting for an inpatient bed. “We put air quotes around the word ‘admit,’ ” he says, adding that hospitalists do H&Ps as well as orders for boarded patients in the ED. “At the two-hour mark, admission orders are released, just as if the patients were already upstairs.”
“Covid has transformed stepdown care.”
Ashlee Ames, MD
Kettering Health
Sometimes, medical nurses from the floor—or even ICU nurses—can float in the ED. Otherwise, “the ED nurses are expected to follow those orders, just like the floor nurses, and that entailed a large amount of nursing education,” says Dr. Harris. “That’s a big lift for the ED staff.”
He and his colleagues considered having all boarders rounded on by one hospitalist, but they abandoned that idea. “The last boarder wouldn’t be seen until noon,” he says. Instead, boarders are distributed among the day hospitalists who prioritize them in the morning to see if any can be discharged. “Most EDs may not be busy until noon so we have a bit more time in the morning to discharge people out.”
In Syracuse, Dr. Leyhane says that day-team hospitalists round on patients boarding in the ED first, with one or two nurse practitioners in the ED in the morning to assist them. The NPs help hospitalists prioritize boarders for beds when those become available, and they let hospitalists know which patients could be discharged. Social workers based in the ED also act as case managers, working with the hospitalists to get a physical therapy evaluation if needed, for instance, so a boarder can go home.
Resources for critical care patients
According to Dr. Ames at Kettering Health, one of the APPs staffing the observation unit each morning assesses all boarded patients waiting for an observation bed to see if some can be discharged. She estimates that between 5% and 10% have improved enough to go home without needing a bed.
“Covid,” Dr. Ames points out, “really pushed everybody toward being more comfortable with discharging patients early or discharging them from the ED.” That’s because the ED and hospital, along with providing more rapid care, have formed multiple collaborations with primary care and outpatient specialty providers for rapid follow-up.
Another result of the pandemic: “Covid has transformed stepdown care,” notes Dr. Ames. “What may have been an ICU patient before is now frequently in stepdown care because the nurses on those units are much more accustomed to a higher acuity level than they were before.” The intensivists in the hospitals her group staffs typically do not take over care for boarded patients in the ED who need critical care. Instead, “they do everything possible to move patients out of the ICU to the floor or to stepdown, to find a bed.”
“Rounding on patients in the hallway isn’t the way we want to provide care.”
Bryan Harris, MD
St. Charles Redmond Hospital
At Jefferson Regional, Dr. Jamal says that in 2020, she officially proposed creating a stepdown unit. That proposal was rejected because the hospital at the time did not want to shrink its ICU census. Now, that option would be a great one to have.
“I may propose that again,” says Dr. Jamal. “It would allow us to maintain bed capacity while rearranging the nurse ratio.”
In Oregon, Dr. Harris says that concerns about boarded critical care patients in outlying hospitals spurred better communications between the transferring and receiving facilities. Confidential texting programs put in place now give ED doctors in transferring hospitals the ability to communicate with ED physicians, hospitalists and subspecialists in receiving ones.
And at some hospitals staffed by Vituity hospitalists, Dr. Miller says that his partners set up tele-ICU consults for boarded critical care patients in outlying hospitals waiting to be transferred. That at least provides better continuity of care until a transfer can take place.
It’s also allowed, Dr. Miller adds, some “borderline” critical care patients to “stay in a community hospital in a regular inpatient bed rather than needing to be transferred to a tertiary center to take up an ICU bed that doesn’t exist.”
When will shortages ease?
The hard part of ED boarding for health care workers, says Dr. Harris, “is the effect on morale. We’re doing our best, but rounding on patients in the hallway isn’t the way we want to provide care.”
At Jefferson Regional, Dr. Jamal expects a break in ED boarding this spring as viruses stop circulating. In Syracuse, Dr. Leyhane expects the short-staffing among nurses and subspecialists in his area to ease later this year as nursing schools supply more graduates and residents and fellows leave training and join the job market.
But Dr. Ames at Kettering Health believes that health care staffing, especially nursing, “is going to take a couple of years to recover.” Meanwhile, she says that hospitalists and administrators are taking a hard look at ways to reduce waste and streamline workflows.
She recently had a conversation with a chief nursing officer who pointed to all the checkbox documentation that nurses in the observation unit have to complete, even though patients there aren’t full admissions. “She said, ‘We really need to revisit observation workflow to make this easier for nurses to do,’ ” Dr. Ames says. “We are all looking strategically at how we can get rid of waste. We just don’t have the luxury of it anymore.”
Dr. Miller notes that hospitals are also revisiting surgery schedules in an effort to smooth them out. “Boarding times are always worse on Mondays because that’s when surgeons have a ton of cases,” he says. “It’s always better on Fridays.”
But he adds that better efficiencies in hospitals won’t cure systemic problems. Now that covid is waning, he expects some health care providers who left the workforce to come back. But the problems backing up EDs go much deeper.
“There needs to be more investment in every level of nursing, not just in inpatient units but post-acute units as well,” Dr. Miller says. “They need better compensation, better Medicaid reimbursement and better working environments.” In the meantime, he adds, ED boarding is “going to be an issue for many more years.”
For more coverage, read “Should you board patients in inpatient hallways?“
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
Published in the March/April 2023 issue of Today’s Hospitalist
