Identifying Strategies to Decrease ED Boarding

Keeping patients in the emergency department (ED) after an admission decision has been made, also known as ED boarding, leads to ED overcrowding. Boarded patients continue to use ED resources and prevent new patients from being seen. Boarding can also have adverse effects, such as higher mortality rates, longer inpatient stays, increased ED length of stay (LOS), and increased waiting room times. Factors that could contribute to longer boarding times include bed availability, hospital staffing, and delays in nurse-to-nurse report or physician consultation. The purpose of this project was to identify strategies to reduce the time a patient is kept in the emergency department after an admission decision has been made. The first objective of the project was to collect and analyze data on current boarding times in the ED at a local community hospital and compare them to the state and national average boarding times. The mean boarding time over the past 3 months at the local community hospital was 56 minutes. The median boarding times captured by Medicare were 47 minutes for the local hospital, 66 minutes for similar sized hospitals in Utah, and 88 minutes for similar sized hospitals throughout the nation. The second objective was to identify barriers in the admission process that could be causing delays in moving an admitted patient to the floor from the ED. For this objective, a data list of the time it takes to complete various admission tasks was created using the electronic medical record (EMR), call logs, and staffing sheets. An admission delay log was also filled out by ED nurses. Based on this log, the top reason for delays was when an on call nurse had to be called in prior to accepting the patient. The third objective was to develop recommendations based on the research findings. To do this, the data list was analyzed using two-tailed t tests, linear regression, random forest, and Pearson R to look for trends that could be increasing the boarding time, such as the consulting physician, certain hospital floors, times of the day, days of the week, or when a nurse was called in from home. Various lists were created to help understand and calculate the data. Staffing and census on the hospital floors and in the ED had no significant effects on boarding time. The closest correlation found using Pearson R was that of Telemetry and BHU census on boarding time, which had weak correlations with R=0.22299 and R=0.15116 respectively. Waiting for the on call nurse to come in created a statistically significant increase in mean boarding time, 72 minutes compared to 55 minutes when no nurse was called in. Using a two-tailed t test, this was a significant difference, p-value=0.00215. The random forest analysis showed that boarding time was very hard to predict, but the top three variables affecting boarding time were floor of admit, floor census, and if a nurse was called in. One of the main recommendations was to make changes that streamline nurse-to-nurse report. The final objective was to present recommendations to key hospital stakeholders, and disseminate project findings to a professional organization. Based on the project findings and recommendations, a presentation was made and presented to key hospital stakeholders. An abstract of the project was sent to the American College of Emergency Physicians. This project identified strategies to decrease ED boarding time. The findings of the project could be utilized to make changes that could prevent ED overcrowding through the reduction in boarding time, total length of stay and ED waiting room times. Making these changes could improve patient outcomes and reduce mortality