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Patient Preferences on Boarding

Patient Preferences on Boarding

Crowding in the ED has been well-established as a problem that poses a threat to public health. Studies show that ED and hospital crowding leads to ambulance diversions, medical errors, delayed care, and increased mortality rates. “Many strategies have been tried to alleviate ED and hospital crowding, some of which involve the entire institution,” explains Peter Viccellio, MD. Using a Full-Capacity Protocol One strategy that aims to reduce ED crowding is the use of a full-capacity protocol (FCP), in which admitted ED patients are redistributed to inpatient unit hallways while they wait for regular hospital beds to open up. Some studies have shown that an FCP can decrease ED wait times, ambulance diversions, and overall hospital length of stay. A potential concern with this approach, however, is that it could reduce patient satisfaction. Recently, Dr. Viccellio and colleagues had a study published in the Journal of Emergency Medicine that examined patient preference and satisfaction with boarding in the ED versus inpatient hallways during times when there were no inpatient beds available for admitted patients. All patients were initially boarded in the ED in a hallway before their transfer to an inpatient hallway bed. “No more than two patients in our study were placed on any inpatient unit and all patients received direct care from inpatient physicians and nurse specialists,” adds Dr. Viccellio. “We didn’t compare a room versus a hallway. Rather, we looked at making decisions about where patients can receive the best care and greatest attention in difficult circumstances when a normal room is not available.” Overwhelming Results According to the results, the overall preferred location after admission...
Overcoming Boarding Issues With Psychiatric ED Patients

Overcoming Boarding Issues With Psychiatric ED Patients

It is estimated that between 6% and 9% of all ED visits are from patients presenting to the emergency room with mental health problems. Unfortunately, many EDs have limited onsite mental health services, forcing many of these patients to endure long holding periods while ED personnel search for available inpatient psychiatric beds. “The problem of boarding mental health patients for long hours—sometimes days—in EDs is considerable and widespread throughout the United States,” says Scott Zeller, MD. Recently published studies have shown that the average boarding time for patients with mental health issues ranges from about 7 hours to 34 hours (Table 1). The causes of boarding in these patients are wide ranging and include a lack of available psychiatric clinicians, requirements for insurance pre-authorizations, and few resources to conduct psychiatric evaluations, among others. Many solutions have been proposed, but these have generally focused solely on increasing available inpatient psychiatric hospital beds rather than considering alternative emergency care designs. “Changing the emergency care design has the potential to provide prompt access to treatment,” Dr. Zeller says. “It might also reduce the need for many hospitalizations.” A Dedicated Psychiatric Emergency Services Model In an effort to reduce average boarding times for patients with mental health issues, one suggested option has been regional dedicated psychiatric emergency services (PES). These units are stand-alone ED specifically for psychiatric patients. At PES facilities, patients are evaluated, receive intensive treatment, and are allowed time for observation and healing. “The goal of PES programs is to stabilize acute symptoms and avoid psychiatric hospitalization when possible,” says Dr. Zeller. “A PES unit can effectively treat patients to the...

Improving the Problem of ED Boarding

According to previous research, boarding inpatients in EDs is one of the main drivers for crowding. In the August 2012 issue of Health Affairs, my colleagues and I explained what is known about the causes and dangerous effects of boarding, strategies that have been demonstrated to alleviate boarding but are underused, and possible regulatory steps that will be needed for hospital leaders to increase efforts to address boarding. Crowding & Boarding: A Costly Problem Inpatients who are boarded in EDs burden already busy ED staff and are kept in brightly lit, loud environments for many hours or even days. Not surprisingly, studies have shown that boarding increases morbidity and mortality, lengthens hospital stays and durations of intubation, worsens pain control, and compromises care. Patients may also have greater exposure to hospital-acquired infections. Boarding also affects measures to which hospitals are held accountable, including time to receipt of antibiotics for patients with pneumonia and the development of bedsores. Furthermore, long waits due to crowding cause some patients to leave EDs before being seen by physicians, robbing them of care and decreasing hospital revenue from their visit. [polldaddy poll=7044226] Boarding occurs when inpatient beds are not available to patients admitted through the ED. This sometimes is the result of hospitals being at full capacity, but inefficient operations may also be partly to blame. Even when hospitals are not at full capacity, hospital leaders who don’t fully understand the costs of boarding may preferentially reserve beds for patients whom they consider more profitable than ED patients (eg, elective surgery patients for whose care is assured reimbursement). Evidence is mixed on whether this...
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