Emergency Department Boarding: Quantifying the Impact of ED Boarding on Patient Outcomes and Downstream Hospital Operations

Abstract

Emergency Department (ED) boarding refers to the delay experienced by patients who are admitted to the hospital from the ED and are waiting for an inpatient bed to become available. Key drivers of ED boarding include an insufficient number of staffed beds in the downstream inpatient units, high demand for medical care, and inefficiencies in patient flow throughout the hospital. Our study quantifies the impact of ED boarding on downstream patient outcomes at a large academic medical center using an instrumental variable design for causal identification. For the average admitted patient, we find that one additional hour of boarding results in a 0.8% increase in the patient’s subsequent hospital length of stay, a 16.7% increase in the odds of the patient experiencing an escalation in their required care level, and a 1.3% increase in their total hospital charges for the visit. We expand upon these findings by estimating the heterogeneous treatment effect of ED boarding across different groups of patients to examine whether they observe different impacts. We find that patient groups differ in their estimated “cost of boarding”: the impact of an additional hour of ED boarding on hospital length of stay varies across patient condition, ESI, and age group. To further this work, we leverage these findings and construct a simulation model to assess potential interventions to improve ED operations by taking boarding cost and patient heterogeneity into consideration.

Note:

Funding Information: No funding.

Conflict of Interests: No competing interest declaration.

Ethical Approval: This study was approved by the Institutional Review Board (IRB) of Yale University. All patient level medical record was anonymized and handled according to HIPAA guidelines. (Approved IRB ID# 2000035544)

Keywords: Empirical Healthcare, Emergency Department, Hospital Operations