Health policy and clinical practice/original researchThe Association Between Transfer of Emergency Department Boarders to Inpatient Hallways and Mortality: A 4-Year Experience
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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2020, American Journal of Emergency MedicineCitation 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.
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.
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Publication date: Available online April 3, 2009.