Inpatient Hallways A ‘Safe’ Option for Stable Patients

Strategy could relieve crowded EDs.

ACEP News
January 2009

By Patrice Wendling
Elsevier Global Medical News

CHICAGO - Transfer of appropriate emergency department-admitted patients to inpatient hallway beds was associated with lower mortality and ICU admission rates than was transfer to standard inpatient beds, according to data from a retrospective cohort study.

In-hospital mortality was 2.6% among 53,020 patients admitted to standard beds and 1.1% among 2,042 patients who went to an inpatient hallway bed.

Dr. Peter ViccellioAdmissions to the ICU, or "bounce-ups," were also higher among the standard bed admissions than among inpatient hallway beds (6.7% vs. 2.5%), Dr. Peter Viccellio and colleagues reported in a poster at the Research Forum of the American College of Emergency Physicians.

In a multivariate regression analysis adjusted for age, the investigators found a similar increase in mortality (odds ratio, 2.5) and ICU utilization (OR, 2.6) among patients admitted to standard beds.

Boarding in inpatient hallways was associated with significantly greater waiting times for admission (median, 624 minutes; range, 439-895 minutes) compared with admission to standard inpatient beds (median 426 minutes, range 306-600 minutes).

As expected, median ED census at time of triage was significantly greater for hallway patients (50 patients) than for standard bed admissions (44 patients), reported Dr. Viccellio, vice chair of the department of emergency medicine at the State University of New York at Stony Brook.

Dr. Viccellio told reporters in a press briefing that the investigators were surprised that the outcomes were so different based on which "side of the door" a patient was transferred to. Although boarding is widely used in other countries to address ED overcrowding, its acceptance in the United States has been slow and gradual because of what Dr. Viccellio called unsubstantiated concerns that it increases patient risk.

"Whenever we talk about this, there are concerns voiced, especially by administration and nurses, that inpatient hallways aren't safe," he said. "However, I think our study gives confidence that boarding of appropriate, stable patients - who make up the majority of patients who are admitted to the hospital - is safe."

During the study period of January 2004 to January 2008, there were 267,981 ED visits, 55,062 hospital admissions, and 1,798 deaths. The 2,042 patients transferred to inpatient hallways represented 4% of total admissions. The analysis excluded dental and psychiatric patients. Hallway admissions were more common from midnight to 8 a.m. (4.5%) than from 8 a.m. to 4 p.m. (3.6%) or from 4 p.m. to midnight (3.1%), the investigators reported.

Stony Brook adopted an institutionwide "full capacity protocol" in 2001 that allowed patients to be transported to inpatient hallways if beds were unavailable. The practice was supported by the New York State Department of Health. No deaths or secondary safety concerns have been reported to date. That is likely a reflection of the lower level of acuity required by the full-capacity protocol for patients transported to the hallways of inpatient units, Dr. Viccellio said.

Patients deemed inappropriate for hallway placement include those requiring ICU or a step-down unit, or those in need of frequent suctioning or high-flow oxygen.

ED patients are identified as appropriate for hallway placement by a physician and are provided a hallway assignment by the hospital bed coordinator. Central monitoring, a call bell, and a privacy screen are also made available in the hallway.

He encouraged hospitals to adopt a similar protocol. But Dr. Viccellio stressed that vigorous monitoring is needed, that any reports of harm from boarding--be it in the ED or on the inpatient unit - should be reported, and that safety issues should be addressed. In contrast to the well-documented safety issues associated with patients boarded in the ED, no such issues related to inpatient hallway boarding have been documented to date, he said.

The most important recommendation Dr. Viccellio said he could offer is for the boarding of admitted patients to be viewed as an institutionwide problem, and a protocol should reflect an institutional solution.

 

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