The Association Between Transfer of Emergency Department Boarders to Inpatient Hallways and Mortality: A 4-Year Experience

doi:10.1016/j.annemergmed.2009.03.005

Annals of Emergency Medicine

Volume 54, Issue 4, October 2009, Pages 487-491

Presented at the ACEP Research Forum, October 2008, Chicago, IL.

https://doi.org/10.1016/j.annemergmed.2009.03.005 Get rights and content

Study objective

We developed and implemented an institutional protocol aimed at reducing crowding by admitting boarded patients to hospital inpatient hallways. We hypothesized that transfer of admitted patients from the emergency department (ED) to inpatient hallways would be feasible and not create patient harm.

Methods

This was a retrospective cohort study in a suburban, academic ED with an annual census of 70,000. We studied consecutive patients admitted from our ED between January 2004 and January 2008. In 2001, a multidisciplinary team developed and implemented an institutional protocol in which admitted adult patients boarded in the ED were transferred to hospital inpatient hallways under select conditions. We extracted data from the electronic medical record system, measuring patient demographics, ED disposition (discharge, admit to floor, admit to hallway), ED length of stay, and inhospital mortality. We report ED length of stay, subsequent transfer to an ICU, and hospital mortality of patients admitted to standard and hallway inpatient beds.

Results

Of 55,062 ED patients admitted, there were 1,798 deaths. Of all admissions, 2,042 (4%) went to a hallway; 53,020 went to a standard bed. Patients admitted to standard and hallway beds were similar in age (median [interquartile range] 55 years [37 to 72 years] and 54 years [41 to 70 years], respectively) and sex (48.2% and 50% female patients, respectively). The median (interquartile range) times from ED triage to actual admission in patients admitted to standard and hallway beds were 426 minutes (306 to 600 minutes) and 624 (439 to 895 minutes) minutes, respectively (P<.001). Median ED census at triage was lower for standard bed admissions than for hallway patients (44 [33 to 53] versus 50 [38 to 61], respectively, P<.001). Inhospital mortality rates were higher among patients admitted to standard beds (2.6%; 95% confidence interval [CI] 2.5% to 2.7%) than among patients admitted to hallway beds (1.1%; 95% CI 0.7% to 1.7%). ICU transfers were also higher in the standard bed admissions (6.7% [95% CI 6.5% to 6.9%] versus 2.5% [95% CI 1.9% to 3.3%]).

Conclusion

Transfer of ED-boarded admitted patients to an inpatient hallway occurs during high ED census and waiting times for admission but does not appears to result in patient harm.

Introduction

One current challenge for emergency medicine is the problem of crowding.1, 2, 3 Although first recognized in the 1980s, emergency department (ED) crowding is more problematic, as highlighted in a 2006 report of the Institute of Medicine titled Hospital-Based Emergency Care: At the Breaking Point.² One of the key findings of this report was that the demand for emergency care visits increased by 26% between 1993 and 2003, from approximately 93 million to 110 million. During the same period, the number of EDs decreased by 425, and the number of hospital beds decreased by 198,000. ED crowding is now recognized as a hospital-wide problem: patients back up in the ED because they cannot be admitted to inpatient beds.¹ As a result, patients are often “boarded”—held in the ED until an inpatient bed becomes available—for extended intervals, up to days. Also, ambulances are frequently diverted from crowded EDs to other hospitals that may be farther away and may not have the optimal services. In 2003, ambulances were diverted 501,000 times, an average of once every minute.²

ED crowding affects care negatively. Not only does it reduce access to emergency medical services⁴ but also it is associated with delays in care for cardiac5, 6 and stroke⁷ patients, as well as those with pneumonia,⁸ and is associated with an increase in patient mortality.9, 10 ED crowding has been associated with prolonged patient transport time,4, 11 inadequate pain management,¹² violence of angry patients against staff,¹³ increased costs of patient care,¹⁴ and decreased physician job satisfaction.¹⁵

As a part of a crowding solution, we developed an institutional policy in 2001 in which admitted patients were transported to an inpatient hallway when standard hospital beds were not available. Although this practice was widely used in many hospitals before the advent of the specialty of emergency medicine, concerns that the inpatient hallways were unsafe for admitted patients have led to widespread objections to this policy. An internal continuous quality improvement review conducted by the inpatient nursing units failed to identify any substantive medical safety issues related to the placement of patients in a hallway. In the current study, we describe our experience with transport of admitted ED patients to inpatient hallways during the last 4 years. We hypothesized that transfer of admitted and boarded ED patients to inpatient hallways was feasible and would not result in excess mortality or ICU patient transfers.

Section snippets

Study Design

We performed a retrospective cohort study to determine the characteristics and outcomes of boarded ED patients transferred to inpatient hallways. Our institutional review board approved the study, with waiver of informed patient consent.

Setting

We studied patients in a single suburban, university-based, academic ED with an affiliated emergency medicine residency training program and an annual census of 70,000.

Selection of Participants

We included all patients admitted to our hospital through our ED during the calendar years

Results

There were 55,062 ED patients admitted to the hospital and 1,798 deaths (3.3%; 95% CI 3.1% to 3.4%) overall. Of all admissions, 2,042 (4%) went to a hallway; 53,020 went to a standard bed. Patients admitted to standard and hallway beds were similar in age (median [interquartile range (IQR)] 55 years [37 to 72 years] and 54 years [41 to 70 years], respectively) and sex (48% and 50% female patients, respectively). Hallway admissions were more likely for patients arriving during the evening shift

Limitations

Our study is limited by the retrospective nature, which may have introduced selection bias beyond the inherent policy-driven bias about who is eligible for hallway placement. We could not control or measure for patient acuity and initial illness burden to better assess the differences between groups. Second, we did not collect data on the effect of our protocol on patient and staff satisfaction, which are also important elements that need to be considered when introducing a similar policy. We

Discussion

According to the definition proposed by the American College of Emergency Physicians, “[c]rowding occurs when the identified need for emergency services exceeds available resources for patient care in the ED, hospital or both.”¹⁶ Asplin et al¹⁷ have proposed a conceptual model to better understand the causes of ED crowding. According to this model, ED crowding may be influenced by input factors (eg, nonurgent visits, “frequent flyers,” influenza epidemics), throughput factors (eg, use of

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This retrospective observational study was performed at an urban tertiary hospital. An ESSW has been operating in this hospital since September 2017 to reduce emergency department (ED) boarding time and only targets patients indicated for admission to the general ward from the ED. Propensity-score matching was performed for comparison with the control group. The primary outcome was ED boarding time, and the secondary outcomes were subsequent intensive care unit (ICU) admission and 30-day in-hospital mortality.
A total of 7461 patients were enrolled in the study; of them, 1523 patients (20.4%) were admitted to the ESSW. After propensity-score matching, there was no significant difference in the ED boarding time between the ESSW group and the control group (P = 0.237). Subsequent ICU admission was significantly less common in the ESSW group than in the control group (P < 0.001). However, the 30-day in-hospital mortality rate did not differ significantly between the two groups (P = 0.292). When the overall hospital bed occupancy ranged from 90% to 95%, the proportion of hospitalization was the highest in the ESSW group (29%). An interaction effect test using a general linear model confirmed that the ESSW served as an effect modifier with respect to bed occupancy and boarding time (P < 0.001).
An ESSW can alleviate prolonged boarding time observed with hospital bed saturation. Moreover, the ESSW is associated with a low rate of subsequent ICU admission.
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Emergency Department (ED) overcrowding is a silent killer. Thus, several studies in different countries have described an increase in mortality, a decrease in the quality of care and prolonged hospital stays associated with ED overcrowding. Causes are multiple: input and in particular lack of access to lab test and imaging for general practitioners, throughput and unnecessary or time-consuming tasks, and output, in particular the availability of hospital beds for unscheduled patients. The main cause of overcrowding is waiting time for available beds in hospital wards, also known as boarding. Solutions to resolve the boarding problem are mostly organisational and require the cooperation of all department and administrative levels through efficient bed management. Elderly and polypathological patients wait longer time in ED. Internal Medicine, is the ideal specialty for these complex patients who require time for observation and evaluation. A strong partnership between the ED and the internal medicine department could help to reduce ED overcrowding by improving care pathways.
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Citation Excerpt :
With the adjusted analysis, we accounted for the decreasing trend in transfers to ICU over time and still found AltCA beds had decreased risk of transfers to ICU, but not for mortality. Previous studies on hallway beds have been limited to these two outcomes and patient preference for inpatient boarding [16,18-21]. Second, our study examined additional key patient safety and quality outcomes: hospital-acquired infections, falls, and 72-hour hospital readmission.
Inpatient hallway beds are one solution to mitigate emergency department (ED) crowding due to boarding of admitted patients. Alternative Care Areas (AltCA) beds are located in inpatient hallways, cardiac catheterization lab, and endoscopy. We examined whether AltCA beds were associated with increased risk of patient safety and quality outcomes: transfer to Intensive Care Unit (ICU), mortality, hospital-acquired infections (HAI), falls, and 72-hour hospital readmission.
Retrospective cohort study of patients age >18 years admitted from the ED to non-ICU beds at an urban, academic hospital. AltCA bed exclusion criteria: dementia, frequent respiratory interventions, contact or airborne isolation, psychiatric admission, and inability to ambulate. The study periods were: pre-intervention 9/1/2014–3/31/2015, transition 9/1/2015–3/31/2016, and post-intervention 9/1/2016–3/31/2017. Data analysis used unadjusted and multivariable analyses which controlled for age, sex, race, ethnicity, insurance, ED triage Emergency Service Index (ESI) level, and telemetry order.
The study included 16,801 patients, with 622 (3.7%) patients in AltCA beds. AltCA beds had younger patients than standard inpatient beds, 57.7 years and 61.7 years; fewer telemetry order, 48.4% and 59.3%; and fewer ESI level 2, 16.1% and 26.2%. AltCA beds had shorter hospital LOS than standard inpatient beds, 2.7 days and 3.4 days. AltCA beds had decreased risk of transfer to ICU −10.6 (95%CI: −18.3, −2.8) and HAI −13.4 (95%CI: −20.3, −6.5) compared to standard inpatient beds.
Patients in AltCA beds did not have increased risk of patient safety and quality outcomes but rather decreased risk of transfer to ICU and HAI than standard inpatient beds.

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: Supervising editors: Debra E. Houry, MD, MPH; Donald M. Yealy, MD

: Author contributions: AV conceived the study, and obtained research funding. AV, AJS, and HCT supervised data collection and analysis. HCT provided statistical advice on study design and analyzed the data. AJS drafted the article, and all authors contributed substantially to its revision. AV takes responsibility for the paper as a whole.

: Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Funded in part by a research grant from the Emergency Medicine Foundation.

: Provide feedback on this article at the journal's Web site, www.annemergmed.com.

: Reprints not available from the authors.

: Publication date: Available online April 3, 2009.

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Health policy and clinical practice/original researchThe Association Between Transfer of Emergency Department Boarders to Inpatient Hallways and Mortality: A 4-Year Experience

Study objective

Methods

Results

Conclusion

Introduction

Section snippets

Study Design

Setting

Selection of Participants

Results

Limitations

Discussion

Ann Emerg Med.

Ann Emerg Med.

Ann Emerg Med.

Ann Emerg Med.

Ann Emerg Med.

Ann Emerg Med.

Ann Emerg Med.

Ann Emerg Med.

J Emerg Med.

Systematic review of emergency department crowding: causes, effects, and solutions

Ann Emerg Med.

Hospital-Based Emergency Care: At the Breaking Point

Crisis in the emergency department

N Engl J Med.

The effect of hospital resource unavailability and ambulance diversions on the EMS system

Prehosp Disaster Med.

Emergency department crowding and ambulance transport delays for patients with chest pain

CMAJ

The impact of a concurrent trauma alert evaluation on time to head computed tomography in patients with suspected stroke

Acad Emerg Med.

Health policy and clinical practice/original research
The Association Between Transfer of Emergency Department Boarders to Inpatient Hallways and Mortality: A 4-Year Experience