Patient volume is increasing in emergency departments (EDs), requiring close management of ED processes and staffing. The boarding of inpatients in the ED is a significant impediment to efficient operations. Boarding time for inpatients in the ED is a function of overall hospital operations. Because roughly 68 percent of hospital admissions are processed through the ED, this “front door” function to inpatient resources is very important to hospitals. Approximately 19 percent of all ED visits result in hospital admission, which makes efficient processing of inpatients a critical determinant of how all ED patients can flow.

The Emergency Department Benchmarking Alliance (EDBA) recognized the need for definitions and convened the first Emergency Department Performance Measurement Summit Meeting on February 23, 2006, in Atlanta. The 18 participating organizations developed the basic definitions of critical time marks and intervals that were adopted across the industry to allow consistent quality measures to be adopted. Those marks and intervals have now served for 20 years to allow comparisons, trending, and application of practice improvement initiatives.¹ It is important to use precise definitions related to boarding that everyone understands and uses consistently. The definitions have been stretched recently.

In 2013, hospitals were required to report ED boarding time—“ED-2”—to the Centers for Medicare & Medicaid Services (CMS) and post it to the CMS Hospital Compare website. That reporting requirement was eliminated in 2022, curiously in the middle of reporting COVID impacts on ED operations.²

ED Time Marks and Time Intervals

There is a basic set of definitions that relate to a point in time for an ED patient. Most of these are now fixed by a computer system:

• Arrival time. The time that the patient is first recognized and recorded by the ED system as requesting services.
• Practitioner contact time. The time of first contact by the physician or advanced practice practitioner (APP) with the patient to initiate the medical screening exam.
• Decision-to-admit time. The time at which the physician or APP makes the decision to place the patient in an inpatient or observation status in that facility.
• Decision-to-transfer time. The time at which the physician or APP makes the decision to transfer the patient to another facility.
• ED disposition time. The time at which a discharged, admitted, or transferred patient physically leaves the ED treatment area.

From those time stamps, ED time intervals are calculated:

• Door to practitioner. Arrival time until practitioner contact time;
• Door to decision. Arrival time to decision time, whether for admission or transfer;
• Boarding time. Decision time to ED disposition time; and
• ED length-of stay. Arrival time to disposition time.

The EDBA analysis of time markers for process flow has found that an arithmetic mean does not characterize the function of the ED as well as the median number. So, the median statistic is used for all time parameters in the EDBA survey.

But conflicts in the definitions have arisen. What was the most important conflict? It was around the time stamp for the decision to admit or decision to transfer. Systems can choose to use a marker specific to the emergency physician, to the admitting physician, to the nursing process (e.g., the bed request, bed coordinator notification, or patient acceptance by the inpatient unit coordinator). It can induce a processing time factor of an hour, or two hours, or four hours, after the documented time the decision to admit occurred. That can artificially erase a significant time interval in the patient’s ED stay and appear to outside observers that the processing of inpatients is occurring in a shorter period of time.

In 2013, when hospitals were required to report ED boarding time—ED-2—to CMS and post it on the Hospital Compare website, patients could better understand the efficiency of hospital operations, no matter the size or complexity of the hospital. A lower time number was better and would mean that patients would not spend extra time in the ED once the decision was made that inpatient services were needed. Changing the definition of decision-to-admit would allow hospitals to report a shorter boarding time, with outside stakeholders unaware. Conversely, emergency physicians would be portrayed as less efficient, because the later time mark would appear to make the door to decision time interval longer, as though we were less capable.

ED Boarding Times, Trends, and Impacts

Click to enlarge.

The EDBA performs an annual data survey, and in 2024 that survey collected performance measures for 1,148 full-service EDs that saw 49 million visits. The data in Graph 1 show that boarding time increases with the volume of patients at the facility. High volume and adult-serving EDs have seen persistently high boarding times, which have resulted in long processing times across all ED patients, dissatisfied ED staff members, and high ED walkaway rates.

As reflected in Graph 2, the data for 2024 show that EDBA members have reduced length of stay for admitted patients, especially in EDs with volumes under 40K. The median boarding time across all EDs has been reduced to numbers that match 2014 and are markedly better than median boarding times reported in 2021 and 2022.

The lengthy boarding of admitted patients in 2021 and 2022 was crippling to the operations of many EDs in the country, producing significant stress on patients, staff, and ED operations. Smaller volume EDs have been more successful in reducing boarding impacts and reducing left-before-treatment-complete rates.

Dissecting the Time Intervals for Admitted Patients

Emergency department managers and ED physicians evaluate their work processes by parameters that mark their use of diagnostic and treatment methods and lead to a quality disposition decision (discharge, admit, or transfer).

Graph 3 demonstrates that about one-third of the time in the ED is in the boarding process. In high volume EDs, that proportion of time is much higher. Inpatient boarding draws on ED resources using beds; nursing time; ED tech time; and needs for feeding, hydration, bathing, and addressing the needs of visitors.

Some hospitals delay decision time based on admitting team preferences and delays in placing an admission order due to processing needs. Some ED managers have reported that the definition of “decision time” has been changed in their facility, to make the “boarding time” length of time look shorter. This could be reflected in the data that are being reported for 2023 and 2024.

Boarding time begins the minute an admission decision is made by the ED physician or APP. This timestamp can be easily and consistently placed in the ED management system. But some hospitals prefer to define boarding as starting at a specific time interval—usually two or four hours—after the admission order. For accurate comparisons, boarding time starts at the decsion to admit. For optimal operations and patient care, boarding time should be short—the best-case scenario is for boarding to last no longer than 30 to 60 minutes.

Impact on Emergency Medicine Practice

Use the correct definitions and measures that allow ED staff to understand their process and how it compares with their peers.

The ED must have a prioritization system for those patients who are in most need of emergency medical care.

Make the ED as timely as possible in the door-to-decision process. Have new patients placed in areas of the ED that are well-designed for full patient assessment and a private interview. A complete patient assessment allows for the most rapid choice of diagnostics and treatment services. Patients with known vulnerabilities like children, seniors, those with mental health conditions, and those with impaired hearing or vision are particularly at risk for inadequate assessment and a poor choice of disposition.

The ED team cannot deliver high-quality and compassionate emergency care without engagement and leadership from the whole hospital. Effective patient flow and discharge pathways are needed out of the ED. The C-suite should be visible each day in the ED at its busiest times, allowing patient-based feedback to the hospital leaders about the care they are receiving, and the discomforts associated with care in hallways, a lack of privacy, and areas that do not allow for family interaction.

Dr. Augustine is the vice president of the Emergency Department Benchmarking Alliance and a clinical professor in the department of emergency medicine at Wright State University in Dayton, Ohio. He serves on the Innovations Advisory Group of the ACEP Emergency Medicine Data Institute. He also serves as medical director for the International Association of Fire Chiefs.

References

1. Welch SJ, Asplin BR, Stone-Griffith S, Davidson SJ, Augustine J, Schuur J. Emergency Department Benchmarking Alliance. Emergency Department Operational Metrics, Measures and Definitions: Results of the Second Performance Measures and Benchmarking Summit. Ann Emerg Med. 2011;58(1):33-40.
2. Weiner SG, Venkatesh AK. Despite CMS Reporting Policies, Emergency Department Boarding Is Still a Big Problem—The Right Quality Measures Can Help Fix It. Health Affairs. Accessed March 29, 2022. https://www.healthaffairs.org/do/10.1377/forefront.20220325.151088/full/.