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Inpatient boarding in the emergency department almost doubled the daily costs of patient care while lowering the value of care patients were receiving.

Holding admitted patients in the emergency department (ED), a practice known as “inpatient boarding,” almost doubles the daily costs of patient care, according to a study published online in the Annals of Emergency Medicine.

The American College of Emergency Physicians and 34 other stakeholder groups deemed boarding a “public health emergency” in a letter to President Biden in November 2022, and, according to corresponding study author Maureen M. Canellas, MD, MBA, of the University of Massachusetts T.H. Chan School of Medicine, and coauthors, boarding negatively affects quality of care and safety, and leads to increased mortality, readmissions, and stays, and decreases patient satisfaction.

“This economic analysis using time-driven activity-based costing adds one more reason why boarding is bad,” wrote the authors.

Financial Impact of Inpatient Boarding

Using time-driven activity-based costing—a granular method often hailed as superior in other industries—the researchers examined 25 patients with acute stroke admitted through the ED at a large comprehensive stroke center. Among the patients, there were 563.8 hours of boarding (398.2 hours of medical-surgical [med/surg] boarding and 165.6 hours of intensive care unit [ICU] boarding) and 1400.1 hours of inpatient care (1195 hours of med/surg inpatient care and 205.1 hours of ICU inpatient care).

Per patient, the total daily cost was $1,856 for med/surg boarding compared with $993 for med/surg inpatient care, according to the study, and $2,267 for ICU boarding versus $2,165 for ICU inpatient care. Travel nursing costs widened these gaps.

Staff Time & Value of Care

The researchers found that boarding also altered how clinicians allocated their time, potentially diminishing patient value even as costs rise.

• Nursing care: ED nurses devoted an average of 293 minutes per med/surg boarder daily, compared to 313 minutes for med/surg inpatients. For ICU patients, ED nurses spent 419 minutes per boarder daily versus 787 minutes for ICU-based nurses.
• Physician care: Neurology attending physicians averaged 25 minutes per med/surg boarder daily (versus 62 minutes for inpatients); residents clocked an average of 52 minutes for boarders versus 90 minutes for inpatients.

“[O]ur observation of less physician time spent for med/surg patients while boarding underscored that despite the boarding phase of care for med/surg patients being nearly twice as expensive, there was potentially less value for the patient,” the authors noted, “at least in terms of time of neurologists’ care.”

Call for Elimination

The researchers concluded, “Using advanced cost-accounting methods, our investigation provides novel evidence that boarding of admitted patients is financially costly, adding greater urgency for elimination of this practice.”