ED Boarding Crisis: How to Reduce Patient Wait Times

This discussion was recorded on June 20, 2023. This transcript has been edited for clarity.

Robert D. Glatter, MD: Welcome. I'm Robert Glatter, medical advisor for Medscape Emergency Medicine. Joining me today is Dr Jessica Kirby, chair of the Department of Emergency Medicine at John Peter Smith Hospital in Dallas, Texas, along with Dr Heidi Knowles, vice chair and medical director, also at John Peter Smith Hospital.

Today we're going to discuss the crisis of boarding in our hospitals throughout the United States. At this point, it's reached a public health emergency. The American College of Emergency Physicians (ACEP) recently put out a press release, and there will be a discussion with members of Congress to really center in on solutions to this crisis. I'll begin with you, Dr Knowles.

Heidi C. Knowles, MD: Thank you so much for taking the time to investigate this issue. It's truly a nationwide crisis right now. The emergency departments across the country are at a true breaking point. This is a decades-long problem that has been looked into and is still, as yet, unresolved.

Boarding happens when a patient comes to the emergency department, they're seen, they're evaluated by a physician, and a decision is made that they need to be admitted to the hospital for something like maybe appendicitis, sepsis, or some other cause.

After the decision to admit, the time from when they're admitted to the time they go to a bed on the hospital side is that boarding time. The goal is usually less than about 4 hours. However, because of shortage in staffing and other causes, the patients end up staying in the emergency department. That can be from hours, to days, weeks, and even months.

Reducing the Volume of Patients Leaving Without Receiving Care

Glatter: Dr Kirby, in your experience in terms of the metrics and boarding and crowding, what's your take on this at your facility?

Jessica J. Kirby, DO: I would agree with Dr Knowles. Boarding has significantly inhibited our ability to care for new patients who present to the emergency room waiting to be evaluated and seen. At 10 months prior to beginning our intervention, we looked at our left without being seen (LWBS) rates and they averaged between 5% and 8%. For us as an institution that sees 350 patients a day, that meant we were seeing up to 50 patients a day [on peak volume days] who presented to be seen and left without being cared for, and we knew we could do better.

We conducted a study to look at factors that affect LWBS in our department. Our thought process was that boarding would be the number-one factor attributing to patients leaving without being seen. We set up an artificial intelligence, computer-generated model to look at factors affecting LWBS. We found that there were two primary factors that affected our ability to care for patients, one being boarding and two being the time it took to get a patient from the waiting room to a bed to be cared for.

We were correct that boarding was significantly adversely affecting our ability to see patients. Truly, besides going to committee meetings and doing interdisciplinary throughput meetings, that was really out of our control. We really wanted to focus on the time it took to get a patient back to a room because that was the one factor we thought that we could influence.

Glatter: In terms of your set-up, do you have a provider in triage? Do you do split flow? Are you doing a vital-signs booth or some type of rapid assessment zone or vertical share model that's been described? I'm curious — are you pulled into full, or are you bringing everyone in, having an empty waiting room? What's your strategy?

Kirby: I'm glad you asked that, Dr Glatter, because we felt a large amount of pressure from the hospital and from other sites to put a physician in triage. To be very frank, we tried that method on several different occasions. What we found as an institution was that it simply shifted our numbers from LWBS to left without completing treatment or left without treatment complete.

We did try that model with very little success. We ultimately ended up doing a pull-until-full model. We had a large amount of transient nursing staff with the nursing shortages. We had many new staff and people who were just exhausted and fatigued post–COVID-19, so we really had to invest in our team and help them understand the goal and what we were aiming to do.

We did a multidisciplinary retreat. We had physicians, APPs, nurses, technicians, and our trauma nurse clinicians, and we all got together to talk about our goals and what a great day in the ED would look like. Once we agreed upon what a great day in the ED looks like, we talked about the barriers to getting there and possible solutions to those barriers. We really got true engagement from the full team before we implemented this pull-until-full concept. In addition to that, we made a few staffing changes, which I'll let Dr Knowles speak to. It really was this pull-until-full concept with some culture building across everyone who touches the patient and the department.

Glatter: Dr Knowles, I'll let you expand upon this.

Knowles: Essentially, we made a few changes where we staffed to the volume, and not just the volume but the time the patients arrive. We have our physicians lined up and ready to go when the patients start coming in the door, based on historical numbers. We also have an intake area, which is seeing patients who are lower acuity, just rapidly treating them, and getting them in and out quickly. We have a couple of 2-hour shifts, which are the beginning of regular 10-hour shifts where the doctors are going out into the waiting room and seeing patients for 2 hours. The patients who have been there the longest are the ones who might already have a workup that's been started and ready to be dispositioned. They see them quickly, get them started, and then discharge or admit them from the waiting room, even.

Unfortunately, one of the downsides of boarding is when we do have to move the patients and the doctors to alternative care spaces and the waiting room. Traditionally, before, when we had higher boarding numbers, we were seeing patients more in the waiting room. Now, we're just seeing them in a few short, hour stints throughout the day.

Collaborative Throughput Efforts: Hospital-wide Engagement and Mental Health Focus

Glatter: Did you work with hospital leadership in terms of, say, elective surgeries being reduced, or in other words, in a collaborative effort to help ease the lack of bed availability in terms of driving throughput? Was there a hospital-wide issue? It's just not an ED issue, as you know, so it's the collaborative aspects I'm interested in.

Knowles: Absolutely. It's 100% not just an ED issue. Unfortunately, it's dependent on so many other players in the hospital system, not just in the hospital, but the whole system. We have begun collaborating with other departments, everything from EVS (environmental services) to get the turnaround time in the rooms cleaned quicker, to working with the surgery department to get their consult times down. We're working with the ICUs to get their patients into the ICU and out of the emergency department quickly. We are working collaboratively with the entire hospital, essentially.

Glatter: Do admitted patients go up to floors — the patients who are stable for floor admissions — in other words, easing the crowding in the ED itself? Is that something you employed?

Knowles: Our hospital is double-bunking inpatients in several of the rooms. They also have created some holding areas for admitted patients. They are going out of the emergency department into the admission holding units and then to a room when the rooms are available.

Glatter: An important issue is the psychiatric patients who are held for days and sometimes weeks. We've heard stories of months with no bed availability, and certainly, this includes pediatric patients as well. This is what ACEP is certainly interested in, and trying to change because this has become a crisis in terms of mental health. I assume you're seeing this at your hospital, correct?

Knowles: We're very fortunate at our hospital because we have a psychiatric emergency center and a psychiatric inpatient unit, so we don't have the holding that other hospitals do. We've heard about the patients who have been in there for weeks or months and the children who have been in the emergency department for 4 weeks waiting for an inpatient bed. As you can imagine, a patient with a psychiatric issue — a loud, busy emergency department is not the ideal place for them. That's happening all over the country. There just are not enough inpatient psychiatric beds.

Glatter: In terms of solutions for psychiatric patients having more rapid assessment, telepsychiatry has been brought online. These seem like fixes that are not really sustainable. It seems like a larger redesign is necessary in the sense of, what if there was a mass-casualty event? If something really, truly happened nationwide, would our emergency departments be able to handle this influx of patients? That's really what I think Congress is being faced with. This is a key issue.

Knowles: This is really a huge problem. If we're already at this stress level, if there's a mass casualty or, God forbid, another pandemic, then what are we going to do with this? We are the safety net for the entire system. If we're at a breaking point, what's going to happen if we have something else, like a major disaster? That's our fear. That's why we're asking Congress to get HHS to convene a summit or a group of stakeholders to figure out what the true issues are and how to fix them.

Driving Change in Lawmaking: Tipping Points and Collaborative Networks

Glatter: What do you think is the key issue that's going to lead to lawmakers making changes in a broad sense?

Knowles: I think, unfortunately, it's what we don't want and what ACEP as an organization does not want — is to get to that tipping point. Sometimes that tipping point is hearing these stories about patients dying in the waiting room. That's happening, unfortunately. When patients are stuck in the waiting room because they can't get back to be seen by a physician, they either leave without getting the care they need or they die. That's the worst-case scenario. The tipping point may be that somebody's family member is affected and that's when they become more alert to the concern.

Glatter: It's unfortunate that it has to take this turn and that someone has to lose their life. People have lost their lives from boarding. These stories that ACEP has put together in a letter in late 2022 illustrate this.

The question is, what do we need? Do we need national guidelines? Do we need a national response? I think that's where this is coming to. Storytelling now might be more effective than providing data, which is what ACEP seems to be doing. Hopefully, this will make changes. People will wake up. The mental health act that they're trying to pass seems like a no-brainer. For whatever reason, it just still hasn't passed.

Going forward, in terms of your hospital, do you have a network within Texas where you collaborate with other hospitals when there seems to be, for example, EDs that are overwhelmed or that are on diversion? What is your setup in terms of how you interact with other hospital systems?

Kirby: We do have what's called the NEDOCS score, and that's an overcrowding score. We update that about every hour in the department. That is something that's shared within a region so you can discern which hospitals have capacity and which ones are overcrowded. I will tell you that most of the time, most of the EDs are overcrowded.

While we work at John Peter Smith Health Network, we are employed by Integrative Emergency Services, a physician-owned and physician-run group. The beauty of that is that we have a network of other medical directors and other facilities that we can connect with to better understand what's going on at neighboring emergency rooms, both in Texas and in neighboring states. That being said, Dr Knowles and I are also connected to ACEP and other national organizations from which we can get information in regard to what's going on at neighboring and other facilities.

Reducing LWBS Rates: Leadership, Staffing, and Team Communication

Glatter: Can you summarize your strategy for reducing the LWBS rate in your facility and how you achieved such a significant reduction? What are the key aspects of this process?

Kirby: One of the key things to make a successful process is to ensure that everyone on your team is aware of the goals and how we plan to get there. In our case, we did the Challenge Accepted retreat. Although it can be physician led, as it was in this case, I think it's really important that all your frontline staff understand what the goals are and our plan to achieve them.

You truly have to invest in your leadership to ensure that they understand the goals and that they have the training to facilitate difficult conversations with frontline staff and ensure that everyone knows that, even if they feel like they have a small role in the process, everyone has a huge role to play in meeting the goals.

Appropriate staffing is huge, and in fairness, although we added physician hours and had this amazing, successful retreat, I think part of our secret sauce, if you will, is that our nursing staffing was at its highest percentage within the past 2 years when we began this initiative. Not only did we have three nurses for every care area, but we have several flow nurses who flow ambulance triage or flow the front-door triage.

Those are truly immeasurable, absolutely necessary positions that perhaps a C-suite tends to underestimate or underappreciate. Please, if you have a large department and you need to work on flow, make sure you have the appropriate staffing and also flow nurses to do that process.

We also met with the neighboring departments. Dr Knowles talked about having meetings with EVS, having meetings with the ICU, and talking to consultants about turnaround time. Those things are all huge and ensuring timely throughput of your department.

Glatter: That's important. Locums and temporary staffing certainly have been something that was so prevalent during the pandemic. It sounds like you have been able to reduce your locums coverage and recruit internally or have some type of program where you're professionally developing nurses to remain at the facility and not to go to locums. Would that be correct?

Kirby: In our last meeting with nursing, we talked about the number of locums nurses that we still have on site, and it was a much larger number than I expected or anticipated. I think one of the greatest challenges with that is that they don't understand your processes and they don't understand your goals or what you're trying to achieve as a team. One thing that is very costly for patient safety and throughput is having those locums at your site. As a physician group and a nursing leadership team, we have tried to invest in all our team members, and we hope in time that the percentage of transient staff get smaller and smaller.

Glatter: Everyone knows certain processes really help the flow. The process has to be team building within each institution, with less reliance on locums as a way to improve outcomes, and also to ultimately reduce your LWBS rate. It all trickles down.

Dr Knowles, I am sure you would agree.

Knowles: Yes, I 100% agree. Everything affects our flow in the department. The more continuity of staffing you have — including doctors, nurses, clerks, and techs — plays a role in our flow.

Also important to mention is that we explained the why to everybody so that they understand it's not just metrics that we want to get people through fast, but the why it's important to get them out of the waiting room so that they don't get worse and they don't decompensate in the waiting room.

Using AI to Enhance Throughput Flow and Predict LWBS Rates

Glatter: You had mentioned AI in terms of your ability to treat patients in the emergency department, especially in terms of throughput flow. Can you elaborate further on that and how you employed AI? I'm very curious about this.

Kirby: We took all our Epic data points over a 2-year period of time, with data points including the time of patient arrival, the time that a physician signed up for the patient, and the time of disposition. We took all the data points from 2 years and we put them through what we call computer-generated algorithms to determine whether this computer could learn which factors best predicted or most influenced LWBS.

For example, we did the linear-regression best-prediction algorithm and several others. With this model, you can set your LWBS to be a specific rate — say, 2%. You can plug in real-time numbers for the day. If we have 15 patients boarding, the average waiting-room time is 15 minutes, and the average door-to-dock time is 10 minutes, what can we anticipate will be a concerning factor to reach our goal?

They'll say, "Well, that is taking too long. Get the patients out of the department," or "Your lab turnaround time is taking too long." This is a tool that can allow departments real time to tweak and modify processes or call for help when you realize that the algorithm is telling you it's not going to reach your goal if these numbers aren't fixed very quickly or very soon.

Glatter: Do you truly need an algorithm to evaluate that? Why can't managerial staff, someone with operational capabilities in the emergency department, or a physician in charge working with nursing determine that? Why do you need AI?

Kirby: I will tell you that as a department, we function very well. If I asked the team leader, the nurse manager, to help me with something because I think it will help with patient care or throughput, I get a response very quickly. Conversely, if I call bed management and tell them that I need a bed, I'm like a squeaky wheel and they get that call often.

Sometimes I think you have to quantify things or have numbers or agreements with which they know that they must act, help, or do something differently. I think if it's a very small, intimate group, a conversation works really well, but sometimes you have to have surge plans or quantitative values that you can share that mean something to someone outside of your department.

Glatter: You're saying AI can spot patterns and things that maybe could be a problem? Is that the operational aspect of your approach?

Kirby: Yes, absolutely.

Glatter: Are the actionable points from AI making a change or a difference in your outcomes? Are you seeing any improvements to date?

I also want to direct this to the residency shortage. I don't know if that will impact the lack of resident physicians as opposed to just nursing. Is there any disconnect that could be part of this and how AI could affect it?

Kirby: We have a very strong emergency medicine residency here. We take 15 residents a year and we have three classes of residents, so we have 45 residents. We have been and continue to be fully staffed from a resident perspective. I don't anticipate that changing any time soon, so our workforce from a resident perspective has not changed.

In regard to AI, we used it to help us determine which factors affect LWBS. We talked about boarding being one and then the time for a patient to arrive to the ED and get to the room as being number two.

For us, that's how we used the model these past 6 months to determine that those are the two factors that we had to play with to get the greatest return on the decrease in LWBS. We are not day-to-day proactively using the tool to communicate with our nurses or team. It is a capability of the tool, but we are not actively using it for that purpose right now.

Glatter: Do you plan to publish your experience or is this more of an internal project?

Kirby: I would love to publish this. I'm told that the 2 years of data is not a large enough at this point to get it published in the type of journal that we'd like it published in. When Dr Knowles and I were looking for studies that show boarding's effect on LWBS, it was very hard to find good studies. I think there is a need in the literature for this, and we plan to continue to get more data points that we can publish.

Glatter: Thank you, again, for a very informative discussion.

Robert D. Glatter, MD, is an assistant professor of emergency medicine at Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. He is a medical advisor for Medscape and hosts the Hot Topics in EM series.

Heidi C. Knowles, MD, is an associate medical director at John Peter Smith Hospital in Fort Worth, Texas. She is also an assistant professor of emergency medicine with Texas Christian University and University of North Texas Health Science Center School of Medicine in Fort Worth, a staff emergency physician at Texas Health Southlake, and an EMS medical director at Trinity Valley Community College in Athens, Texas.

Jessica J. Kirby, DO, is an emergency medicine physician in Fort Worth, Texas, and is affiliated with JPS Health Network-Fort Worth. She received her medical degree from Arizona College of Osteopathic Medicine of Midwestern University.

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