Contrast this to the emergency departments that processed admitted patients at a higher rate than the mean in the data survey, presented on the third row of Table 1. These departments had a lower walkaway rate, with a dramatically reduced ED boarding load per day. Ranging in volume from 18,000 to 119,000 patients per year, these emergency departments served an average of about 57,000 patients annually. The average boarding time per patient was about 2.5 hours, and the overall LOS for admitted patients was 6.5 hours. They still lost about five patients each day.

The emergency departments that processed admitted patients at a faster rate than the mean are represented on the fourth row of Table 1. These departments had a walkaway rate lower than the universe of all emergency departments and had dramatically reduced ED boarding hours per day. The departments ranged in annual volume, up to 128,000 patients. The average boarding time per patient was about 92 minutes, and the overall LOS for admitted patients was less than 3.5 hours. They averaged only 2.4 patients per day who left before treatment was complete.

Financial Implications

Using some revenue estimations based on Table 1 data, the financial impact of boarding on the emergency department is clear.

Table 1. Boarding Time and Performance Measure

The Medical Expenditure Panel Survey (MEPS) is a publicly available, ongoing, national dataset from the Agency for Healthcare Research and Quality that presents information on health care use and expenditures, including charges for ED service.² It uses a large-scale survey of the US non-institutionalized civilian population, with a stratified, multistage probability sampling design. Details are available from this dataset, but nationally, ED charges are now more than $2,500 per visit, with payments more than $1,000.^3,4

So what’s the financial impact on the hospital of the constipated emergency department?

Start with some simple assumptions based on one of the emergency departments from the second row—the average department. The ED patient generates revenue of $1,000 for the hospital and $110 for the emergency physician, plus revenue above direct costs of $6,000 per average patient admitted to the hospital. That means the average emergency department seeing about 44,000 patients a year and admitting 16 percent of them generates $44.1 million annually in direct ED revenue, plus serves as the front door for admitted patients, who generate $43 million annually above the direct cost. That totals ED patient revenue of $238,356 per day.

Now consider the constipated emergency department. The boarding issue is influencing the care of every one of the 192 patients a day who present to this department. Each of the 40 patients admitted on an average day (typically worse on Mondays) has four extra ED hours. That results in the average ED stay for admitted patients of almost 10 hours, where nurses and techs have to provide services equivalent to those at an inpatient unit. It means the ED bed that’s occupied isn’t available for other ED patients, who are constantly arriving. This means that all ED patients receive care for at least two hours longer than at an average emergency department, with a significantly higher number of patients simply walking away.