AT COOPER UNIVERSITY HEALTHCARE in Camden, N.J., Jean-Sebastien Rachoin, MD, MBA, head of hospital-based services, said he and his colleagues deploy two different interventions to relieve ED boarding.
One is inpatient hallway beds. “The idea is to have patients managed in a hallway bed on the floor instead of in a hallway in the ER,” he said. Only patients being boarded in ED hallways (not in rooms or cubicles) are taken to floor hallway beds.
“It’s designed to move patients closer to their care teams,” said Dr. Rachoin, “and expedite definitive treatment.”
“It’s fascinating that when patients move to a floor hallway, somehow room beds suddenly open up.”
Jean-Sebastien Rachoin, MD, MBA
Cooper University HealthCare
First implemented at Stony Brook University Hospital in Stony Brook, N.Y., the intervention has since been adopted throughout the U.S. and Canada. Patients in floor hallway beds must be 18 or older, able to ambulate, not be agitated or confused, and be on only four liters or less of oxygen.
Exclusion criteria include ICU patients; those on BIPAP or ventilators; those who need transmission-based isolation or airborne precautions; patients who require suctioning or an NG tube; those who are combative or disruptive; and patients with persistent, acute nausea with vomiting or diarrhea or a GI bleed.
Once the ED identifies appropriate patients, nurses ask if they’d be OK being transferred to a floor hallway bed. All hallway beds come with a curtain and a table patients can use to eat, as well as a call button to summon a nurse.
“Nursing ratios are taken into account for these beds,” Dr. Rachoin said. “Patients are getting better care there than in the ED.”
Evidence backing the use of hallway beds
As for the evidence behind the intervention, Dr. Rachoin said that 11 studies have looked at hallway beds. Many of those have explored patient preferences on where they want to be boarded—and the majority preferred being in an inpatient hallway instead of one in the ED.
One 2020 study of nearly 17,000 patients found that hospital length of stay for hallway beds was shorter than for regular beds (2.7 vs. 3.4 days). The same study looked at outcomes on other metrics—transfer to ICU, mortality, infections, time to medications—between inpatient hallway beds and other beds. Researchers found no difference.
Dr. Rachoin shared another observation: “It’s fascinating that when patients move to a floor hallway, somehow room beds suddenly open up.” Part of the reason why, he added, is that nurses don’t love having patients in the hallway. “They do their best to move them right away into a room.” Typically, patients spend less than 24 hours in a hallway bed before a room becomes available.
His hospital has been using hallway beds during two Joint Commission inspections. “As long as you have a robust inclusion and exclusion policy and respect egress and fire exits, the Joint Commission has no issue.” Because of egress and safety issues, “we limit the number of hallway beds to two per unit.”
Discharge lounge
The second intervention at Cooper University HealthCare is a discharge lounge. Discharge lounges are used exclusively for patients ready to leave the hospital who are waiting for a ride home.
“We have a nurse-based protocol,” Dr. Rachoin explained, “that allows nurses to decide which patients are eligible to move from the floor to the discharge lounge after the discharge order is placed.” Moving patients to the lounge frees up an inpatient bed for an admission being boarded in the ED.
A few studies have looked at outcomes with discharge lounges, although most of the evidence, he noted, is from poster presentations or oral reports at conferences.
One 2014 study done in the U.S. and published in BMJ Quality Improvement Reports found that the use of a discharge lounge over four months lowered the percentage of patients being boarded in the ED for six hours or more (25% to 16%). The same study found that discharge lounges also increased the percentage of discharges taking place before noon from 33.4% to 41.5%.
At Cooper University Hospital, patients being sent to the discharge lounge must be 18 or older, able to ambulate and not have any confusion. They must be being discharged to home and already have all their medications, or at least not need any medications on the day they’re using the lounge.
The discharge lounge is staffed by two techs Monday through Friday from 8 a.m. to 8 p.m. Dr. Rachoin showed 2025 monthly data through July from his hospital on discharge lounge volumes, with roughly 500 patients being discharged using it per month. (The discharge lounge is also, he noted, used for patients being discharged directly from the ED, an additional 200 patients per month in many months.) On average, he said, patients spend between an hour and a half to two and a half hours there waiting for rides.
One downside: Staff buy-in can be a challenge. “Once nurses discharge a patient to the lounge, their reward is getting a new patient,” said Dr. Rachoin.”So they have a whole new assessment, chart, interview, documentation set. They don’t have a lot of motivation to do that.”
It can also be hard to identify which patients safely meet inclusion criteria. And there can be competing demands on the care team if they have new or crashing patients or patients making a lot of demands.
As he put it: “The discharge lounge might go low on the list.” Still, the experience of the patients studied who’ve used the lounge in his hospital has been positive.
Strategies to reduce ED boarding: Faster discharges to post-acute facilities.
Trinity Health Michigan works closely with its post-acute care network to craft transition collaboration agreements. Read more here.
Strategies to reduce ED boarding: Surrounding patients with outpatient resources.
Lehigh Valley Health Network has put in place a triage process that clinicians use with all patients presenting to the ED. Read more here.
Phyllis Maguire has been Executive Editor of Today’s Hospitalist since 2006. Based in Bucks County, Pa., her health care interests are hospital medicine and long-term care options. She also likes zydeco, hiking, and reading memoirs and romances.
I think the real issue that is simply taken as a given is that the care in the ER will be substandard.