Project description:ObjectivesEmergency department boarding is the practice of caring for admitted patients in the emergency department after hospital admission, and boarding has been a growing problem in the United States. Boarding of the critically ill has achieved specific attention because of its association with poor clinical outcomes. Accordingly, the Society of Critical Care Medicine and the American College of Emergency Physicians convened a Task Force to understand the implications of emergency department boarding of the critically ill. The objective of this article is to review the U.S. literature on (1) the frequency of emergency department boarding among the critically ill, (2) the outcomes associated with critical care patient boarding, and (3) local strategies developed to mitigate the impact of emergency department critical care boarding on patient outcomes.Data sources and study selectionReview article.Data extraction and data synthesisEmergency department-based boarding of the critically ill patient is common, but no nationally representative frequency estimates has been reported. Boarding literature is limited by variation in the definitions used for boarding and variation in the facilities studied (boarding ranges from 2% to 88% of ICU admissions). Prolonged boarding in the emergency department has been associated with longer duration of mechanical ventilation, longer ICU and hospital length of stay, and higher mortality. Health systems have developed multiple mitigation strategies to address emergency department boarding of critically ill patients, including emergency department-based interventions, hospital-based interventions, and emergency department-based resuscitation care units.ConclusionsEmergency department boarding of critically ill patients was common and was associated with worse clinical outcomes. Health systems have generated a number of strategies to mitigate these effects. A definition for emergency department boarding is proposed. Future work should establish formal criteria for analysis and benchmarking of emergency department-based boarding overall, with subsequent efforts focused on developing and reporting innovative strategies that improve clinical outcomes of critically ill patients boarded in the emergency department.

Project description:ImportanceEmergency department (ED) boarding times have increased rapidly, but their health equity outcomes are unknown.ObjectiveTo investigate whether prolonged ED boarding is associated with increased perceived racial discrimination and dissatisfaction and whether associations vary between patients from marginalized racial and ethnic groups vs non-Hispanic White patients.Design, setting, and participantsThis is a cross-sectional study of hospitalized adults who boarded in the ED during internal medicine admissions at a large, urban hospital in Boston, Massachusetts, from June 2023 to January 2024. Equal proportions of non-Hispanic White patients and patients from marginalized racial and ethnic groups (American Indian or Alaska Native, Hispanic, non-Hispanic Black and/or African American, and multiracial) were selected randomly.ExposureThe duration of ED boarding was categorized as less than 4 hours (reference), 4 to less than 24 hours, and 24 or more hours.Main outcomes and measuresPrimary outcomes were odds of reporting (1) discrimination via the Discrimination in Medical Settings scale, and (2) dissatisfaction via the adapted Picker Patient Experience-15 questionnaire. Marginalized race and ethnicity was tested as an effect modifier. Multivariable logistic regression models adjusted for patient age, sex, language, and insurance payer.ResultsOf 598 patients approached, 527 were enrolled, and 525 completed the surveys (response rate, 87.8%). The mean age (SD) was 60.6 (18.7) years, 300 patients (57.1%) were female, 246 patients (47.3%) identified as non-Hispanic White, and 274 (52.7%) were from a marginalized racial or ethnic group. In total, 135 (25.7%) boarded less than 4 hours (reference), 202 (38.5%) boarded 4 to less than 24 hours, and 188 (35.8%) boarded 24 hours or longer. Compared with less than 4 hours, boarding 24 hours or longer was associated with increased perceived discrimination (odds ratio [OR], 1.84; 95% CI, 1.14-2.99; P = .01). An increased association was observed in the subgroup of patients from racial and ethnic marginalized groups (OR, 2.36; 95% CI, 1.20-4.65; P = .01); effect modification was not significant (P for interaction, .10). For all patients, boarding 24 hours or longer was associated with increased dissatisfaction with care (OR, 1.77; 95% CI, 1.03-3.06; P = .04); effect modification was not significant (P for interaction, .80).Conclusions and relevanceIn this cross-sectional study, hospitalized patients who boarded in the ED 24 hours or longer reported more discrimination and dissatisfaction with care, which may disproportionately affect patients from marginalized racial and ethnic groups. As ED boarding times increase nationally, it is critical to recognize their potential to exacerbate health inequities and to respond with equity-focused solutions.

Dataset Information

Effect of a Boarding Restriction Protocol on Emergency Department Crowding.

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Materials and methods

Results

Conclusion

Publications

Effect of a Boarding Restriction Protocol on Emergency Department Crowding.

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