What Downstream Changes Could Ease ED Boarding Problems?

May 3, 2023
Panelists at CMS Quality Conference say health system needs more flexibility in capacity in inpatient, post-acute care settings to reduce boarding issues

A roundtable discussion at this week’s CMS Quality Conference examined the widespread practice of “boarding” patients in emergency departments, which is associated with increased mortality, medical errors, readmissions, and hospital-acquired infections.

Session moderator Sean Michael, M.D., regional chief medical officer for the Centers for Medicare & Medicaid Services, started by giving a definition of boarding as the practice of holding or physically keeping an admitted patient in the ED after the decision is made to admit them, usually because there are no hospital beds available.

Michael noted that in at least 14 studies, the practice of boarding has been associated with increases in hospital mortality. “There is an association with longer hospital length of stay, which further exacerbates capacity problems because as patients stay longer in the hospital, that ties up capacity in the hospital for the next incoming patients. There are at least seven studies that show decreased patient experience and decreased satisfaction among patients and their families,” he said. “There's increased risk-adjusted hospital spending, and there are very many studies that demonstrate a significant association the variety of serious adverse events including medication errors, misdiagnosis, errors, readmissions, unintended unplanned ICU upgrades, hospital acquired infections, and care that doesn't adhere to best practice guidelines, and violence against healthcare workers and burnout. So the harms here are pretty indisputable.”

“We've had a lot of my ED leadership chafe at the idea of having ED boarding on an ED dashboard because they say this is not something that's within our control,” said Eric Wei, M.D., M.B.A., senior vice president and chief quality officer at New York City Health + Hospitals. “They agree the issue is downstream — it's inpatient crowding, length of stay, and then it's what happens on the back end of that — to skilled nursing facilities, short-term rehab, to getting the appropriate kind of supportive care in the community so that they can go back to the to the home setting. One example downstream that we see is that Medicaid covers the acute hospitalization, but doesn't cover anything after that, so a lot of patients get stuck in the inpatient setting. They could be stuck there for months or years. If 30 to 60 to 80 of your inpatient beds in each hospital are taken up by these patients who have nowhere to go, it's just less room and less flexibility to admit patients who have a more acute medical problem. It just blocks the whole system.”

“I've heard people say that ED boarding should be a never event. We already know how much harm it causes,” Wei said. “We actually need to treat this problem like a never event, where you do root cause analyses rather than just reacting to the symptoms, and telling people to try harder, work faster, do better. We need to address the root causes downstream and actually fix those. Otherwise, the short-term fixes that we put in place, we're just going to be dealing with Whac-A-Mole a couple of weeks later, a couple of months later, every flu season.”

Wei wondered if we have the right quality measures in place to address the issue.

Arjun Venkatesh, M.D., M.B.A., is chair of emergency medicine for Yale School of Medicine and the chief of emergency medicine for Yale New Haven Hospital. He's also a scientist at Yale Center for Outcomes Research and Evaluation, which works with CMS on quality measure development. “What we find is that for many big, hard problems in healthcare, one measure doesn't get us there,” he said. “It's often a set of complementary measures that are aligned with a set of financial incentives that are aligned with a variety of supportive improvement mechanisms.”

Venkatesh says he looks optimistically toward a future where there is not just a single measure that's going to solve this problem. “It may require multiple quality measures that are aligned with a variety of other programs, both from the public side and regulatory levels, but also potentially within the private sector — a variety of other forces that together change this equation, so that it starts becoming higher value care to get patients through a hospital care system faster — to get them into post-acute care, to get them into home health care, as opposed to the current system, which sort of favors this board in the emergency department, long hospital length of stay model.”

Martin Reznek, M.D., M.B.A., is professor and execute vice chair for clinical operations and education in the Department of Emergency Medicine at the UMass Chan Medical School/Umass Memorial Health. He noted that there's actually very little data related to the financial drivers on ED boarding. It appears that on the revenue side, there are financial drivers for the hospital that can exacerbate boarding, he said. There is a difference for elective admissions vs. ED admissions in terms of income for the hospital and that is a potential driver that leads to boarding, Reznek said.

Filling the hospital with inpatient admissions is a revenue driver for the hospital, Reznek said. It's a system that's designed to do that. “But I think that some of the financial methodologies that we do in healthcare in general related to cost accounting are actually hiding the true cost of what it means to the institution to board a patient,” he said. “In the ED, you've got a team that is highly trained and highly skilled at initial diagnosis, stabilization and treatment and then transitioning care. Now you are asking them to go out of that skill set and be equally as efficient as the inpatient floor in doing inpatient stuff — transitioning to the post-acute facilities and things like that. And of course, that's going to be more expensive, but I think it needs to be more palpable.”

Venkatesh said he asks residents in the training program at Yale to imagine a world where the nursing homes in their community all have vacancy rates of 20 to 25 percent, which is roughly the average in many communities in America right now. Somebody at a nursing home is unable to make it in because they tested positive for COVID. That means that that nursing home now can't accept a new arrival for the course of that day. That trickles back to an inpatient service that's been waiting days to be able to discharge a patient since they've got record length of stay in almost every hospital. “They face their own boarding issue, which is a lack of exit options,” he said. “That trickles down into the emergency department, where a patient can't get up to a floor, which then trickles to our waiting room in the emergency department, where a patient leaves without being seen.”

Venkatesh stressed that we have created a system that leads to an inability to access emergency care. “We know that the patients who leave without being seen are at higher risk of worse outcomes. We know that they're not getting that promise that EMTALA (Emergency Medical Treatment & Labor Act) was supposed to create around the country to create access to care for everybody. Worst of all, we know that it's inequitable that those who are more likely to leave the demurrage department without being seen and have a poor outcome are more likely to be people of color, and more likely to be socially vulnerable for a variety of different reasons.”

Essentially, Venkatesh said, we have designed a system that doesn’t have enough capacity. The only way that we can work our way out of this is to design a system with both a sufficient capacity to provide safe care to all people in all settings and get patients into the right setting, as well as the flex that we need, he said.

“That means creating financial incentives to have something like empty beds in a hospital or the financial incentives or the regulatory levers that would allow you to have flexible capacity in a hospital to use space differently and flexible capacity in a skilled nursing facility, flexible capacity in long-term care,” Venkatesh added. “Until we're able to create a system a little bit more like the military and a lot less like hospitals that are trying to optimize profits, where we have a concept of readiness, where we have capacity that's ready to go if there's a supply shock or a demand shock, and we need acute care capacity to take care of patients, we're going to keep running into this problem. If we keep trying to live at 100 percent, we know what's going to happen. We're going to continue to fail. I think that's where this is really going to require transformative change.”

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