Strategies to reduce ED boarding: Surrounding patients with outpatient resources

SHADI JARJOUS, MD, MBA is chief of hospital medicine and vice chair of operations for the department of emergency and hospital medicine at Lehigh Valley Health Network in Pennsylvania’s Lehigh Valley. Now part of Jefferson Health, Lehigh Valley Health has 15 hospitals served by a hospitalist team of about 200 physicians and advanced practice clinicians.

According to Dr. Jarjous, the health system has put in place a triage process they use with all patients presenting to the ED. That process includes timeline and communication expectations for patients who will be admitted.

For those patients, ED clinicians use secure messaging to communicate admissions referrals to a designated triage hospitalist. That triagist reviews the patient’s chart and responds with a disposition decision.

“Our hospitalist-run virtual bridge clinic will see high-risk patients within two days of discharge.”

Shadi Jarjous, MD, MBA
Lehigh Valley Health Network

When the decision is to admit, the triage service tries to place an admission bed request within 15 minutes of the ED’s initial referral. (If a bed request isn’t made within 15 minutes, an ED clinician may place streamlined admit orders.) The hospitalist assigned to that admitted patient should complete admission orders within 30 minutes—and finish the entire admission within two hours of being assigned the patient. To make the admission process even faster, hospitalists may obtain a history via telemedicine.

To help clinicians decide to either admit, observe or discharge patients from the ED, hospitalists and ED colleagues also crafted an evidence-based algorithm that outlines how patients need to be worked up in the ED and what red flags in presentation make patients more appropriate for observation or admission vs. discharge.

Avoidable admissions and outpatient resources
Another key strategy Dr. Jarjous and his colleagues have pursued is reducing the number of avoidable admissions to be able to discharge patients directly from the ED.

To do so, they first had to decide which diagnoses might potentially be more appropriate to treat in the outpatient setting. They identified the following list: syncope, dizziness, A fib, gastroenteritis, lower back pain, and mild COPD or mild CHF exacerbation.

But preventing avoidable admissions—and reducing readmissions among patients discharged after a hospital stay—is possible only “if you surround patients with the right resources when discharging them,” Dr. Jarjous pointed out. Here are resources that health system has put in place:

• Acute care bridge clinic: This virtual clinic, which is staffed by hospitalists, is held seven days a week from 8 a.m. to 5 p.m. The clinic is used not only for patients discharged from the ED who don’t have a primary physician, but also for hospital discharges that have a high risk of readmission (or rising readmission risk once they get home). The clinic also sees patients discharged on remote monitoring or home health who need to have their care escalated.

“Based on patients’ Epic readmission risk score, our hospitalist-run virtual bridge clinic will see high-risk patients within two days of discharge,” said Dr. Jarjous. The virtual clinic sees any discharged patient with rising readmission risk at home within four days. Discharged patients with low readmission risk who don’t have a primary physician will be seen at the clinic within seven days.

The bridge clinic handles medication reconciliation as well as dose changes, med reorders and follow-up labs. The clinic also links patients to resources like specialist referrals or remote patient monitoring. “Occasionally,” Dr. Jarjous said, “the clinic sends a patient back to the ED, but that’s rare.”

The clinic’s biggest impact, he noted, is in both seven- and 30-day readmissions. “That makes sense,” he said, “because hospitalists are more comfortable caring for acutely sick patients.”

• Remote patient monitoring: A nurse-led team monitors vitals and provides care management for high-risk patients. Eligible diagnoses for remote home monitoring include CHF, COPD, hypertension, post-cardiothoracic surgery (CABG or valve), post-renal transplant, sepsis, and covid or other respiratory viral illness.

“Hospitalists in the bridge clinic serve as the primary for some of these patients so they can access the remote monitoring program,” Dr. Jarjous noted. He also pointed out that remote patient monitoring has lowered readmissions across all diagnoses for three years in a row. In fiscal year 2025, for instance, the use of remote monitoring lowered the percentage of these patients being readmitted from 18.3% to 14.8%.

• Transition of care (TOC) associates. These personnel are onsite in Lehigh Valley Health EDs Monday through Friday from 8 a.m. to 4: 30 p.m. For patients who aren’t being admitted, TOC associates do predischarge outreach to schedule outpatient appointments.

For patients who will need home remote monitoring, TOC associates ensure that the right equipment is delivered. They also help support the acute care bridge clinic.

• Lehigh Valley Physician Group access coordinators. The health system’s physician group embeds 16 access coordinators across 70 sites, including EDs. They work Monday through Friday, 7:30 a.m. to 4 p.m.

“They are also available after hours on weekends via secure messaging,” Dr. Jarjous said. These staff coordinate patient appointments through direct scheduling of new and follow-up primary care and specialty appointments, as well as other outpatient services.

Coordinators who are offsite reach out to patients by phone to either schedule a primary care visit or an appointment with the acute care bridge clinic.

Since putting these outpatient resources in place, the health system has learned that any follow-up visit type—in-person, video or phone—helps. According to Dr. Jarjous, in-person and video visits help lower 30-day readmission rates.

• Outpatient care navigators: These personnel, Dr. Jarjous said, do post-discharge assessments for social determinants of health. They also help patients maintain access to their own medical records and make sure that all transition of care visits have been completed.

Better management of boarded transfer patients
Another major category of patients being boarded in the ED are transfers within the network. “It’s really important that patients waiting to be transferred are managed appropriately,” Dr. Jarjous said. “Waiting time depends on various challenges including transport and bed availability.”

Hospitalists may manage these patients based on how sick they are and how long they’re waiting in the ED.

For transfer patients waiting less than eight hours, ED physicians may consult hospital medicine at their discretion. But once patients hit that eight-hour waiting mark, said Dr. Jarjous, “we recommend they consult us. Our job is to start their inpatient care as soon as possible.”

When transfer patients have been waiting more than 24 hours, “we ask the hospitalists to reassess their need to be transferred,” he pointed out. “Sometimes, when you complete their work-up, you can change their disposition and keep them where they are—or send them to a different site.”

Strategies to reduce ED boarding: Hallway beds and discharge lounges. 

Cooper University HealthCare deploys two different interventions to relieve ED boarding. Read more here.

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.

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.