Every emergency physician has, at one time or another, scanned the emergency department and noticed that patients who should be headed to other departments for care are still there. The time from the decision to admit a patient until the inpatient unit accepts the patient for the transition of care is called “boarding,” and its impact on patient care has been discussed in a previous ACEP Now article.¹

ED leaders have been handed significant responsibility for ED processing, including admitted patients, and must carefully manage the department’s resources. What hasn’t been discussed is the fact that the overall effect of inpatient boarding on an emergency department’s bottom line has been vastly underestimated.

The Emergency Department Benchmarking Alliance (EDBA), a not-for-profit organization that offers resources to ED leaders, has collected data on ED performance measures that provide insight into the operational and financial impact of ED boarding. In the data, EDBA discovered clear associations between boarding time, average length of stay (LOS), and the rate at which patients leave before treatment is complete.

The EDBA data on boarding are from 1,195 emergency departments participating in EDBA data surveys completed in 2014 and 2015. The results have been compiled into Table 1.

A Matter of Time

According to respondents, the median length of ED boarding for patients going to an inpatient unit averaged 109 minutes across all emergency departments. Because some departments have boarding times substantially longer than 109 minutes, the cohorts were divided into three sets based on the actual boarding times.

The EDBA found a substantial effect of boarding on the LOS of all patients, including those who were treated and released. There is a profound effect on the ultimate marker of patient dissatisfaction: leaving the emergency department before treatment is complete.

The emergency departments that slowly offload admitted patients, with a boarding wait time of 240 minutes or more, are presented on the second row of Table 1. These departments, “constipated” with too many boarding transfers kept waiting, have more than double the number of patients who leave before treatment is complete compared to the average department, and they have an average of 233 boarding hours per day in the department. Ranging in volume from 33,000 to 130,000 patients per year, these emergency departments served an average of about 70,000 patients annually. The average boarding time per patient was almost six hours, and the overall LOS for admitted patients was almost 10 hours. In constipated departments, more than 5 percent of patients left—about 10 per day.