Emergency Room Boarding

Abstract A patient who is boarded is one who remains in the emergency department even after they have been admitted to the hospital. Boarding patients in the emergency department has become a problem for many hospitals in America today. It has affected the health and safety of patients and staff in numerous ways. This is an issue that needs to be resolved soon or the overall quality of healthcare in America will drop substantially. BOARDING PATIENTS IN THE EMERGENCY DEPARTMENT 3 Boarding Patients in the Emergency Department.

A major issue affecting hospitals in the United States today is the process of boarding patients in the emergency department (ED). It is the primary cause of overcrowding in a hospital and affects more than 90% of hospitals in America (Lowes, 2001). The practice of boarding or “holding” patients endangers the safety of hospital staff and the patients themselves. It causes delays in care and even worse ambulance diversions. Emergency department visits climbed fourteen percent from 1992 to 1999 (Lowes, 2001). This shows that boarding patients is a risk to the incoming ED patients.

The nursing shortage in America is a direct contributor to the practice of holding patients in the ED. When there are beds available for patients in the hospital, there might not be personnel to staff them (Lowes, 2001). There have been instances where there were unoccupied inpatient beds but just no nurses to care for them. In some parts of the country, the scarcity of nurses has reached crisis proportions. Another cause for the use of boarding patients is hospital downsizing, which instantly affects the amount of inpatient rooms. The latter part of the twentieth century experienced major hospital closings and ED closings.

Hospitals were forced to close due to budget cuts or not enough staffing. When hospitals close, it causes overcrowding in the hospitals that stay open. Overcrowding causes longer waits and fewer beds, which in turn leads to boarding patients (Lowes, 2001, p. 81). A hospital is a system with patients flowing through it, from admission through testing and treatment to discharge. Boarding results from backups in this flow. Inpatient beds are not readily available to patients admitted through the emergency department therefore they must be BOARDING PATIENTS IN THE EMERGENCY DEPARTMENT 4  retained in the halls of the ED. Backups in the Emergency Department have been occurring in America for the past decade. (Pines,2006).

There are no positive aspects to this issue, but the negative aspects of this issue are very detrimental to the health care system in our country. When a patient enters a hospital and expects care right away, they do not want to be waiting around in a bed in the hall of an emergency department. Waiting a few minutes is okay but once it starts to be hours, people can get unruly. Patient satisfactory plummets when they are put in that situation.

The Centers for Disease Control (CDC) found for patients judged to be in critical condition, more than ten percent waited more than one hour to see a physician in the ED. This is a dangerous drawback because most illnesses are time dependent so waiting longer to seek care could be harmful to the person’s health (Pines, 2006). Studies have shown that overcrowding indirectly increases medical errors. “Many of these errors are of omission and not commission since the emergency staff must simultaneously care for inpatients and focus on the new emergencies coming in the door,” says Cowan (2005) (p. 291).

The law requires on-call doctors to respond to emergencies immediately or receive a fine of up to $50,000 (Lowes, 2011, p. 71). If doctors and nurses are tending to multiple patients at a time and running back and forth between them, there is bound to be some medical errors. It must be stressful caring for multiple types of illnesses in one shift. Stress causes people to make unnecessary mistakes; but these types of mistakes are about life or death. Several recent studies looking at mortality rates in patients seeking emergency care conclude that the rate of death is substantially higher during times of crowding (Richardson, 2006, p.213).

A huge effect of boarding patients/overcrowding emergency departments is ambulance diversion. It occurs when a hospital ED cannot accommodate any more emergency patients so BOARDING PATIENTS IN THE EMERGENCY DEPARTMENT 5 they must send them to another hospitals ED. Ambulances can drive around for unnecessary amounts of time trying to find a hospital with room in the emergency department for their victim. This can be scary for the victim. They present a huge health risk for patients seeking urgent medical attention.

Ambulance diversions wouldn’t be an issue if overcrowding did not exist. Schull (2003) believes that ambulance diversion is driven by the boarding of patients and is not otherwise related to issues of staffing within the ED itself. (p. 467-476) The longer a patient waits to be cared for, the more likely they are to walkout prior to receiving care. Richardson (2006) states that the number of patients with serious illness differs little between patients who left and those who waited for care. (p. 462). Another reason a person would want to walkout is if they knew they were going to be boarded.

If they do not believe they need urgent care, most likely that person would just walkout. Boarding also increases the total length of stay in the hospital, which leads to further back ups in emergency care. According to Krochmal (1994), “several studies document a total hospital length of stay to be a full day longer among patients boarded in the emergency department versus patients with similar illnesses promptly placed in the inpatient units” (p. 265). This issue is affecting nursing and health care in general. First of all, it interferes with the patient-centered care model.

This model states that continuity teams care for patients during their stay. If patients spend portions of their stay in the ED and then in an inpatient room, continuity is impossible because they aren’t isolated to one department. Nursing specialists are now refusing to take emergency room calls. They feel more inclined to decline calls from the ED because they are no longer a source of paying patients. Some hospitals have turned to paying specialists $2,000 a day for ED coverage (Lowes, 2001). BOARDING PATIENTS IN THE EMERGENCY DEPARTMENT 6.

As stated earlier, this issue is affecting nursing because of an increase in medical errors. It obviously does not look good for a hospital to have a lot of medical errors. Sometimes these errors are the responsibility of the nurses. They have so many patients to deal with at once and oversights are made. Once again, this all finds its root in the main issue of the scarcity of nurses. If hospitals were more adequately staffed, nurses would have help with tending to patients and they generally would have less patients in their direct care.

That would take care of a whole slew of problems if we could just solve the nursing shortage crisis. Donna Mason, board member on the Emergency Nurses Association (ENA), said, “when you think that 60 percent of all Americans will visit an ER in their lifetime, it really is all of our responsibility to determine how to solve this issue of crowding and the shortage of ER nurses” (Cowan, 2005). That means six out of every ten people will see an emergency room at some point and most of those people will probably be boarded for a period of time.

Patient satisfactory will drop and people will start to complain. The worst thing is for a hospital to have a low satisfaction rate because patients will be nervous to receive care. Most people involved in the health care system want to resolve this problem as soon as possible. There are some ways to resolve this issue but most hospitals do not have the resources for it to be accomplished. One way is to expand the size of the hospitals emergency department. The funding for that endeavor would need to be millions of dollars though.

Many hospitals have little funding and simply cannot afford to build an emergency department. Another option at resolving the issue is being used at a facility in Oklahoma City. They have employed people as “bed staff coordinators” to monitor and track patient admissions and discharges to maintain the best patient flow. They have examined peak times in the hospitals ED and have decided to supplement physician staff with nurse practitioners and physician assistants. BOARDING PATIENTS IN THE EMERGENCY DEPARTMENT 7 They now have more staff tending to patients at peak times.

This will help with the pace of care and to make it more efficient (Cowan, 2005). Working on fixing the triage system can help solve this crisis as well. Many emergency departments have a triage system that applies to all incoming patients no matter the type or severity of illness. Usually there is a line at triage, which defeats the actual purpose of it. Triage is used to swiftly sort out patients to where they need to go to receive care effectively. For example, patients who look well but have a sprained ankle can receive care and skip the whole process of looking for vital signs and other tests.

Triage can focus more time on patients that require more evaluation. The hospital in Oklahoma City aforementioned created two triage areas with a charge nurse and a triage nurse working more closely together to provide faster patient care (Cowan, 2005). Another way to fix this problem is by urging the legislators to stop regulating hospitals to the extreme. Fixing a patient to nurse ratio is a recipe for disaster. Patients are placed in hallways (or boarded) with no direct nursing observation. The ratio should be more flexible especially during times of overcrowding.

Some hospitals have agreed to “float” more nurses to the ED during crowded times (Derlet, 1995). A way we can indirectly prevent boarding of patients is to carefully evaluate staffing needs. Taking care of the hospital staff can prevent burnout and early retirement. The nurses, physicians and surgeons are the core of every hospital. Obviously, a hospital cannot run without them. They deserve to be taken care of because they are saving patients lives daily and they need a time to rest and recuperate.

If hospitals push their staff to the point of overworking them, it is just a set up for the eventual burnout of that staff member. That will eventually lead to an even larger shortage of nurses or physicians, which causes more problems with ED boarding. BOARDING PATIENTS IN THE EMERGENCY DEPARTMENT 8 Most hospitals today are boarding patients in the emergency department. It is not a very safe and effective practice. Some hospitals are forced into it because of nursing shortage or overcrowding. I believe it is a major cause of low patient satisfaction in hospitals.

Who would want to wait to be cared for while lying in a hospital bed in the hall of the emergency department? It is too hectic and stressful to be in there waiting there especially if you do not need emergency care. The safety of patients is at risk because of negligence by nurses and long waits. The safety of staff is also at risk because of overwork. Overall, this is a crisis that needs to be resolved. If hospitals keep up this practice, the health care system in American will become even worse than what it is now. BOARDING PATIENTS IN THE EMERGENCY DEPARTMENT 9.

References Cowan, R. M. (2005). Clinical Review: Emergency department overcrowding and the potential impact on the critically ill. Crit Care; 9(3), 291-295. Derlet, R. W. (1995). Prospective identification and triage of nonemergency patients out of an emergency department: A 5-year study. Annals of Emerg Med; 25:215-223. Retrieved from http://www. ncbi. nlm. nih. gov/pmc/articles/PMC2672221/pdf/wjem-9-0024. pdf Krochmal, P. (1994). Increased health care costs associated with ED overcrowding. Am J Emerg Med; 12(3), 265-266. Lowes, R. (2001).

What will it take to solve the ER crisis? Medical Economics, 78(23), 70-2, 77, 81. Retrieved from http://search. proquest. com/docview/227782380? accountid=28588 Pines J. M. (2006). The association between emergency department crowding and hospital performance. Acad Emerg Med; 13(8), 873-878. Richardson, D. B. (2006). Increase in patient mortality at 10 days associated with ED overcrowding. Med J Aust; 184(5), 213-216. Schull, M. J. (2003). Emergency department contributors to ambulance diversion: a quantitative analysis. Annals of Emerg Med. 41(4), 467-476.

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