Hospital Boarding Crises: The Impact of Urgent Versus Prevention Responses on Length of Stay

40 Pages Posted: 24 Jun 2019 Last revised: 30 Jun 2020

See all articles by Temidayo Adepoju

Temidayo Adepoju

Boston University - Questrom School of Business

Anita Tucker

Boston University - Questrom School of Business

Helen Jin

Boston University - Boston Medical Center

Chris Manasseh

affiliation not provided to SSRN

Date Written: September 30, 2019

Abstract

Healthcare policy makers use wait-time metrics to encourage hospital managers to improve patient experience. For example, in 2002, Massachusetts mandated that hospital managers develop processes to identify and respond to boarding crises, which occur when emergency department patients experience long waits for inpatient beds. Performance improvement theory suggests that patients would be better served by preventing boarding crises rather than responding urgently after they occur.
To empirically test this theory, we use data from a Massachusetts hospital with two different physician-based processes related to boarding and patient flow. First, to comply with the state mandate, the hospital developed processes to identify when the hospital is in a boarding crisis, and subsequently requests that physicians prioritize patient discharge (urgent response). Second, physicians can use pre-discharge orders (PDO)—optional written communication about discharge barriers—to avoid unnecessary discharge delays for patients approaching discharge. Ensuring that beds are freed up as soon as possible might prevent boarding crises from occurring (prevention response).
Our data supports the existence of a tradeoff between these two responses. Surprisingly, and counter to our hypothesis, the state-mandated urgent response is associated with an increased inpatient length of stay (LOS) of 49.7%. We suspect that the LOS-increasing effect of high levels of hospital occupancy that occur for all patients during a CY outweigh any reduction in LOS gained by the few patients who might be discharged early due to the CY. We also find that CY does not improve ED outcomes. The prevention response is associated with a 24.7% reduction in inpatient LOS. We conduct counterfactual analyses at the day-level to find that if physicians use PDOs for all of their patients, it would increase the number of discharges per day and substantially reduce the number of boarding crises. We conclude that the state policy has unintended negative consequences that stymie hospital efforts to create longer-term improvement in their hospitals.

Keywords: Health Care; Hospitals; Information Systems; Application Contexts/Sectors; Government; Regulations; Empirical Operations; Discharge Coordination

Suggested Citation

Adepoju, Temidayo and Tucker, Anita and Jin, Helen and Manasseh, Chris, Hospital Boarding Crises: The Impact of Urgent Versus Prevention Responses on Length of Stay (September 30, 2019). Boston University Questrom School of Business Research Paper No. 3405617, Available at SSRN: https://ssrn.com/abstract=3405617 or http://dx.doi.org/10.2139/ssrn.3405617

Temidayo Adepoju (Contact Author)

Boston University - Questrom School of Business ( email )

595 Commonwealth Avenue,
Boston, MA 02215
United States
4138470548 (Phone)

Anita Tucker

Boston University - Questrom School of Business ( email )

595 Commonwealth Avenue
Boston, MA MA 02215
United States

Helen Jin

Boston University - Boston Medical Center ( email )

One Boston Medical Center Place
Boston, MA 02118
United States

Chris Manasseh

affiliation not provided to SSRN

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