Boarding of Pediatric Patients in the Emergency Department

Approved by the ACEP Board of Directors January 2012

The problem of boarding emergency department (ED) patients is multifactorial with causes that span the entire health care delivery system. Boarding is a major patient safety issue. To optimize patient care, it is critical to reduce the boarding of pediatric patients awaiting inpatient bed placement as well as the overall length of stay of patients treated and discharged. By reducing patient boarding, treatment of patients in non-treatment areas such as hallways can be limited, and the number of patients leaving prior to evaluation or completion of medical treatment can be reduced. Approaches used to achieve these goals include:

  • Creating departmental metric goals for the components of ED length of stay;
  • Constructing an action plan to move the metrics from baseline to target;
  • Identifying and addressing frequent obstacles to efficient care delivery both inside and outside of the ED; and
  • Changing inefficient processes both within the ED and in inpatient capacity management.

Most EDs are running at or above perceived maximum capacity on a daily basis. Although ED personnel are well trained to respond to unexpected major disasters, many EDs simply do not have the resources to surge beyond their already overtaxed environment. Operations must be structured to maximize efficiency and mitigate prolonged ED stays.

Although there is no universally accepted gauge for process improvement success, the decline of the left without being seen (LWBS) rate has shown to be a positive indicator. As most pediatric emergencies present to general EDs, specific tools that shorten pediatric length of stay within the greater milieu should be utilized. The American College of Emergency Physicians supports the definition and monitoring of the following metrics for pediatric patients for the purpose of creating and gauging operations for improvement:

  • Door to bed
  • Door to first provider
  • ED arrival to ED departure for patients treated and discharged
  • ED arrival to ED departure for patients treated and admitted
  • Admit decision to ED departure for admitted patients

The American College of Emergency Physicians supports previously identified processes as safe and efficient methods to achieve a reduction in overall patient length of stay:

  • Immediate bedding.
  • Quick registration.
  • Bedside registration for secondary demographic information.
  • Electronic patient tracking systems.
  • Team approach to family-centered care.
  • Inpatient capacity management with processes such as early discharge, aggressive inpatient bed management techniques (e.g. OR time management, hiring a “bed czar”), and streamlining admission and discharge processes.1  

The American College of Emergency Physicians supports use of tools that have specifically reduced pediatric length of stay:

  • Triaging pediatric patients with attention to physiologic identifiers of severity of illness, including history of poor color, decreased activity, underlying disease or chronic illness, and prematurity with complications, and upgrading triage category appropriately.
  • Utilizing pulse oximetry in triage to identify hypoxia at triage in children with respiratory symptoms.
  • “Fast track” of appropriate pediatric patients, which reduces length of stay without impact on outcome.
  • Activating a specific pediatric team within general EDs during peak hours.
  • Creating pediatric specific advanced triage protocols and nurse implemented order sets along with clinical care guidelines.
  • Instituting a hospital-wide2 full capacity protocol to facilitate the admission of pediatric patients from the ED.

 1. ACEP Task Force Report on Boarding; Emergency Department Crowding: High-Impact Solutions. April 2008
 2. ibid 

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