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August 26, 2021

Emergency Department “Boarding” At Seemingly All-Time High Levels

As many of you as emergency physicians undoubtedly know (and have experienced), crowding in the emergency department (ED) has been an issue for years—in some cases causing ED “boarding,” which can keep patients in the ED for days (or longer) due to the lack of available inpatient beds or space in other facilities where the patient could be transferred.

Unfortunately, ACEP has been hearing recently from many of you across the country that ED boarding is at an all-time high. The reason for this is multi-factorial, but mainly has to do with significant staffing shortages in hospitals and an influx of patients (both COVID- and non-COVID-related) who are extremely sick (potentially because some of them delayed care during the last year and a half).  

There is ample research that shows that ED crowding leads to increased cases of mortality related to downstream delays of treatment for both high and low acuity patients. Boarding can also lead to ambulance diversion, increased adverse events, preventable medical errors, lower patient satisfaction, violent episodes in the ED, and higher overall health care costs. Therefore, it is important that we try to better understand what is causing this significant increase in ED boarding and try to take steps to mitigate the effects this phenomenon is having on patients (and the physicians who treat them).

Numerous news articles have picked up on this unfortunate state-of-affairs. A recent article in the New York Times highlighted the impact that nursing shortages that are plaguing EDs and hospitals are having on patient care. Another more local article from Southeast Texas discussed the experience of physicians working at hospitals in this area. They state that patients are waiting hours to be seen in the ED, and once there, hours, or even days to be admitted to the hospital. According to one official in the region, the main cause of this back-up of patients is a shortage of around 2,000 nurses.

We at ACEP are obviously extremely concerned about what’s happening in our EDs and hospitals, and have been meeting with external partners, including hospital associations, to try to develop potential solutions. From an advocacy perspective, we have reached out to the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission to see what federal actions can be taken to address this issue.

Currently, the only mechanism that CMS uses to monitor ED boarding is through its Medicare hospital quality reporting programs. CMS’ hospital quality reporting programs tie hospitals’ Medicare payments to their performance on quality measures. In both the inpatient and outpatient quality reporting programs, there are quality metrics on ED boarding. The inpatient quality metric measures the median time from admit decision time to time of departure from the ED for ED patients admitted to inpatient status and the outpatient metric measures the median time from ED arrival to time of departure for patients discharged from the ED.

Interestingly, CMS, despite our objections, has decided to sunset the inpatient measure starting in 2024. According to CMS, there is limited evidence that ED boarding is associated with adverse outcomes such as in-patient mortality (despite ACEP and other organizations presenting studies and other evidence to the contrary.) CMS states that it still thinks ED boarding is an important issue to track, but going forward starting in 2024, will only use the outpatient metric to monitor ED boarding.

CMS also does not believe that removing the inpatient measure will impact hospitals’ commitment to reducing ED boarding times. If that is the case, it begs the question of what other incentives or penalties (if any) would in fact spur hospitals to address this issue. Is there in fact anything the federal government can do that will have a meaningful impact on reducing ED boarding? ACEP is meeting with senior CMS officials next month to hopefully get an answer to that very question.

While addressing the overall challenge of ED boarding is a herculean endeavor (and may take a while), one small step that ACEP is trying to do in the meantime is figure out ways to support you during this extremely difficult time. For example, we have heard that some of you are being financially penalized for lower patient satisfaction scores, as patients understandably are frustrated that it is taking a long time to be seen and treated. However, you should not be penalized for something that is way beyond your control—and ACEP is working on this issue.

If you have ideas about how to address ED boarding, or experiences from your own institution you would like to share, please send them my way. We can use the data or other information in our advocacy efforts.

Until next week, this is Jeffrey saying, enjoy reading regs with your eggs.

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