ED to Wards: Beating the Boarding Problem

Boarding has been a growing problem over the last decade and may worsen – at least in the short term – with the fuller implementation of the Affordable Care Act, according to experts who are calling for hospitals to implement proven remedies.

Hospital efficiency has suffered as institutions seek to cut costs while coping with a rising influx of uninsured and Medicaid patients. That financial pressure will not improve under health care reform, at least not initially, as millions more Medicaid patients are likely to seek care in the ED when they cannot access primary care, Dr. Jody Crane, emergency department faculty for the Institute for Healthcare Improvement, Cambridge, Mass., said in an interview.

Medicaid pay is already low, and an estimated 8 million more Medicaid patients will visit EDs annually after reform. In addition, as Medicare dials back its reimbursement to hospitals and physicians to help fund the Affordable Care Act, Va. That will put a squeeze on already tight hospital margins, he said.

"Every hospital is going to have to do the same or more with less," said Dr. Crane. Boarding – holding patients in the ED while they wait for admission to inpatient services – can be costly, reduces patient satisfaction, and has been shown to ultimately increase length of stay and mortality.

"Boarding in some hospitals is a capacity issue, but in others it’s also a management issue," Dr. Crane pointed out. Technical issues, including matching resources to the demand coming through the door, are also factors, he said.

"Ultimately, a coordinated effort is needed between the ED and the hospitalist to ensure quality transitions of care that maximize both health and financial outcomes," said Dr. Franklin A. Michota, director of academic affairs in the department of hospital medicine at the Cleveland Clinic. "Each hospital does need to analyze where their bottlenecks exist and whether a staffing solution is part of the answer. But the ED also needs to look at the accuracy and quality of their triage and their ability to adequately prepare the patient for the trip upstairs."

"For example," Dr. Michota continued, "sending a patient upstairs with sickle cell crisis and inadequate pain control just ties up the hospitalist unnecessarily and will delay the hospitalist in getting to the next new admission. Or failing to order a CT scan that would have sent a patient to the operating room and bypass the medical hospitalist altogether will again just delay getting to the next admission.

"Everything relies on everything else....the chain is only as strong as its weakest link."

Indeed, "the primary reason it’s a hard problem to fix is because it’s so multifactorial," said Dr. Jesse Pines, associate professor of emergency medicine and health policy at George Washington University in Washington, D.C.

What Works?

A recent study in Health Affairs showed that many hospitals still are not taking advantage of proven strategies to reduce boarding – among them, so-called smoothing of elective surgical schedules, active bed management by hospitalists, and the "full capacity protocol" that was developed by Dr. Peter Viccellio and his colleagues at the State University of New York at Stony Brook.

"This paper is another in a long series of wake-up calls about the dangerous practice of ‘boarding’ admitted patients in [emergency departments]," ACEP President Dr. David Seaberg said in a statement. "I just hope that hospital administrators and legislators smell the coffee. Their leadership is critical to changing the flow of patients from the front door of the emergency department to the inpatient floors of the hospital."

Emergency departments and hospitals can work together to find ways to improve efficiency, but several important ingredients are needed, Dr. Pines said. The Health Affairs article (2012;31:1757-66 [doi: 10.1377/hlthaff.2011.0786]) cites certain protocols that work, "but you need people to make them work," he said. "You need a strong leader in the ED who can get buy-in from the emergency group. ... You also need a supportive administration and medical staff to make it happen."

It is important to have a local quality improvement group whose members can look at the overall process by which patients get moved from the ED to inpatient services, and examine how patients are managed in the ED after they are admitted, Dr. Pines said. After the existing process is analyzed, hospital staff can identify and address the inefficiencies causing the delays.

The inefficiencies are highly particular to each facility, and often to each day and each shift in the ED and on inpatient wards, he said.

Staffing shortfalls – especially inpatient nursing staff – can be a major contributor to bottlenecks, Dr. Crane said. In response to financial pressures, many hospitals are reducing nursing staff, resulting in increased nurse-to-bed ratios. "That prolongs the inpatient length of stay," he said, because it leads to more work per nurse and more delays in admitting and discharging patients.

There has been a recent administrative trend toward real-time capacity management,which can be an effective way to accommodate the variation in admissions over time.. With this approach, if there is not an identified demand for nurses, they can be sent home or told not to come to work.This ability to change staffing levels according to real-time needs can be an effective way to accommodate the variation in admissions over time

Handoffs and Beds

Dr. Crane contends there are three specific elements to improving patient flow: the physician handoff, the nursing handoff, and bed efficiency.

The physician handoff can be made more efficient by optimizing the coordination between hospitalists and emergency physicians. Due to the high variation in arrival of admissions from the ED and the low numbers of admitting hospitalists at certain times, patients can queue in the ED awaiting admission orders, Dr. Crane noted.

So now, many emergency physicians write holding orders – which have an expiration time – until the patient can be admitted. Holding orders allow the patient to be moved out of the ED, Dr. Crane said. Until recently, emergency physicians have been reluctant to write holding orders, but this trend has reversed because it can be dramatically effective.ACEP now endorses the practice and notes that any associated risk is limited.

The unpredictability of admissions "creates all kinds of logistical nightmares handing off from the emergency department to the floor nurse," Dr. Crane said. Just adding more nurses is not necessarily the answer, and, in general, hospitals don’t have the money to add staff. Instead, hospitals need to better align existing resources and staff. For instance, nurses should probably not be transporting patients or cleaning rooms. That can be done with lower-priced and less-resource-intensive staff, Dr. Crane said.

Bed capacity is the third major element that hospitals should address to reduce boarding, according to Dr. Crane. Demand from the ED cannot be controlled, but on the inpatient side, hospitals can "smooth" the elective surgery schedule by moving more procedures to the middle and end of the week so that all the beds aren’t occupied early in the week. And that is not necessarily easy: "When you change block schedules, you get into cultural issues" with surgeons who do not want to have to see patients on the weekends, Dr. Crane said.

There are also practical issues limiting weekend care. Namely, the typical services such as physical therapy and case management are not routinely present on the weekends. As such, patients who could otherwise be discharged stay in their beds until Monday, when bed demands from the ED and OR increase dramatically. Bed capacity could be improved if hospitals can find ways to make services like testing and therapy available on weekends, and find surgeons and other consultants who will round on Saturdays and Sundays. That might mean hiring a physician’s assistant or other midlevel provider to cover.

Observation Units

Hospitals have also started making use of "observation" status for patients or adding observation units.

At Mary Washington Hospital, where Dr. Crane practices, a team of physicians, nurses, and administrators is designing a streamlined protocol for observation patients. Instead of the standard admission history and physical, an abbreviated assessment has been designed, incorporating use of the ED record and a brief assessment format. Consultations are reduced, and evidence-based pathways are being created for a variety of admitting diagnoses. Patients are treated as outpatients unless test results indicate they need to be moved to the inpatient side, and due to the reduced workload, nurses may be able to work comfortably with higher bed-to-nurse ratios.

The target is to hold patients for observation for 24 hours or less, Dr. Crane said.

Because observation patients are considered outpatients, insurers will pay the hospital less for the visit than if the patient is admitted, Dr. Pines noted, and it leaves the patient vulnerable to higher expenses than just an ED copay.

Another recent study in Health Affairs found that observation stays have been rapidly increasing – from 86.9 observation stays per 1,000 inpatient admissions in 2007 for Medicare beneficiaries to 116.6 in 2009 (Health Affairs 2012;31:1251-9). Of every 1,000 Medicare beneficiaries, 2 were under observation each month in 2007 and almost 3 were under observation each month in 2009. Meanwhile, inpatient admissions per 1,000 declined.

The Sharp Stick of Regulation

Voluntary efforts by hospitals may not be enough, said Dr. Sandra Schneider, former president of the American College of Emergency Physicians. Because hospitals are still paid for the patients who are boarded, they might not see the hidden costs of boarding, she said.

"We have to change that playing field if we want to get serious about [boarding]," Dr. Schneider said.

Among the game changers she cited are the increasing requirements for public reporting on quality measures, including those related to boarding.

Currently, hospitals get paid more by Medicare if they report certain inpatient quality measures. On the outpatient side, emergency departments report on the median time from ED arrival to ED departure for discharged patients and on patients who leave without being seen. In addition, it is now voluntary for hospitals to report on the average time patients spend in the ED before being admitted as an inpatient, and the average time patients spend in the ED after admission but before leaving the ED for their inpatient room.

Data from hospitals that have reported on these measures can be found on the Hospital Compare website.

The Joint Commission is also revisiting its standard on patient flow in the ED, which will go into effect in January 2013. Among other things, the commission is considering defining an episode of boarding as any case in which a patient remains in the ED 4 hours or more after a decision has been made to admit or transfer that patient.

Dr. Pines said that hospital administrators will be motivated both by public reporting imperatives and by Joint Commission standards. Dr. Crane, however, said that "until there are some significant incentives to moving patients upstairs in a timely manner, what’s going to drive senior executives is finance." He thinks that these new standards may help, but more incentives may be needed, such as penalties imposed if boarding limits are exceeded.

Australia, Canada, the United Kingdom, and other developed countries impose such limits and levy penalties.

Hospital Compare data – which will be more fully reported at the end of the first quarter of 2013 – “is going to show us once and for all where the median is and who are the outliers,” Dr. Schneider said. It’s hoped that the outliers will "realize they don’t just have a boarding problem – they have a serious boarding problem," she said.

"If not, then we may have to do what the rest of the world is doing."

Boarding has been a growing problem over the last decade and may worsen – at least in the short term – with the fuller implementation of the Affordable Care Act, according to experts who are calling for hospitals to implement proven remedies.

Hospital efficiency has suffered as institutions seek to cut costs while coping with a rising influx of uninsured and Medicaid patients. That financial pressure will not improve under health care reform, at least not initially, as millions more Medicaid patients are likely to seek care in the ED when they cannot access primary care, Dr. Jody Crane, emergency department faculty for the Institute for Healthcare Improvement, Cambridge, Mass., said in an interview.

Medicaid pay is already low, and an estimated 8 million more Medicaid patients will visit EDs annually after reform. In addition, as Medicare dials back its reimbursement to hospitals and physicians to help fund the Affordable Care Act, Va. That will put a squeeze on already tight hospital margins, he said.

"Every hospital is going to have to do the same or more with less," said Dr. Crane. Boarding – holding patients in the ED while they wait for admission to inpatient services – can be costly, reduces patient satisfaction, and has been shown to ultimately increase length of stay and mortality.

"Boarding in some hospitals is a capacity issue, but in others it’s also a management issue," Dr. Crane pointed out. Technical issues, including matching resources to the demand coming through the door, are also factors, he said.

"Ultimately, a coordinated effort is needed between the ED and the hospitalist to ensure quality transitions of care that maximize both health and financial outcomes," said Dr. Franklin A. Michota, director of academic affairs in the department of hospital medicine at the Cleveland Clinic. "Each hospital does need to analyze where their bottlenecks exist and whether a staffing solution is part of the answer. But the ED also needs to look at the accuracy and quality of their triage and their ability to adequately prepare the patient for the trip upstairs."

"For example," Dr. Michota continued, "sending a patient upstairs with sickle cell crisis and inadequate pain control just ties up the hospitalist unnecessarily and will delay the hospitalist in getting to the next new admission. Or failing to order a CT scan that would have sent a patient to the operating room and bypass the medical hospitalist altogether will again just delay getting to the next admission.

"Everything relies on everything else....the chain is only as strong as its weakest link."

Indeed, "the primary reason it’s a hard problem to fix is because it’s so multifactorial," said Dr. Jesse Pines, associate professor of emergency medicine and health policy at George Washington University in Washington, D.C.

What Works?

A recent study in Health Affairs showed that many hospitals still are not taking advantage of proven strategies to reduce boarding – among them, so-called smoothing of elective surgical schedules, active bed management by hospitalists, and the "full capacity protocol" that was developed by Dr. Peter Viccellio and his colleagues at the State University of New York at Stony Brook.

"This paper is another in a long series of wake-up calls about the dangerous practice of ‘boarding’ admitted patients in [emergency departments]," ACEP President Dr. David Seaberg said in a statement. "I just hope that hospital administrators and legislators smell the coffee. Their leadership is critical to changing the flow of patients from the front door of the emergency department to the inpatient floors of the hospital."

Emergency departments and hospitals can work together to find ways to improve efficiency, but several important ingredients are needed, Dr. Pines said. The Health Affairs article (2012;31:1757-66 [doi: 10.1377/hlthaff.2011.0786]) cites certain protocols that work, "but you need people to make them work," he said. "You need a strong leader in the ED who can get buy-in from the emergency group. ... You also need a supportive administration and medical staff to make it happen."

It is important to have a local quality improvement group whose members can look at the overall process by which patients get moved from the ED to inpatient services, and examine how patients are managed in the ED after they are admitted, Dr. Pines said. After the existing process is analyzed, hospital staff can identify and address the inefficiencies causing the delays.

The inefficiencies are highly particular to each facility, and often to each day and each shift in the ED and on inpatient wards, he said.

Staffing shortfalls – especially inpatient nursing staff – can be a major contributor to bottlenecks, Dr. Crane said. In response to financial pressures, many hospitals are reducing nursing staff, resulting in increased nurse-to-bed ratios. "That prolongs the inpatient length of stay," he said, because it leads to more work per nurse and more delays in admitting and discharging patients.

There has been a recent administrative trend toward real-time capacity management,which can be an effective way to accommodate the variation in admissions over time.. With this approach, if there is not an identified demand for nurses, they can be sent home or told not to come to work.This ability to change staffing levels according to real-time needs can be an effective way to accommodate the variation in admissions over time

Handoffs and Beds

Dr. Crane contends there are three specific elements to improving patient flow: the physician handoff, the nursing handoff, and bed efficiency.

The physician handoff can be made more efficient by optimizing the coordination between hospitalists and emergency physicians. Due to the high variation in arrival of admissions from the ED and the low numbers of admitting hospitalists at certain times, patients can queue in the ED awaiting admission orders, Dr. Crane noted.

So now, many emergency physicians write holding orders – which have an expiration time – until the patient can be admitted. Holding orders allow the patient to be moved out of the ED, Dr. Crane said. Until recently, emergency physicians have been reluctant to write holding orders, but this trend has reversed because it can be dramatically effective.ACEP now endorses the practice and notes that any associated risk is limited.

The unpredictability of admissions "creates all kinds of logistical nightmares handing off from the emergency department to the floor nurse," Dr. Crane said. Just adding more nurses is not necessarily the answer, and, in general, hospitals don’t have the money to add staff. Instead, hospitals need to better align existing resources and staff. For instance, nurses should probably not be transporting patients or cleaning rooms. That can be done with lower-priced and less-resource-intensive staff, Dr. Crane said.

Bed capacity is the third major element that hospitals should address to reduce boarding, according to Dr. Crane. Demand from the ED cannot be controlled, but on the inpatient side, hospitals can "smooth" the elective surgery schedule by moving more procedures to the middle and end of the week so that all the beds aren’t occupied early in the week. And that is not necessarily easy: "When you change block schedules, you get into cultural issues" with surgeons who do not want to have to see patients on the weekends, Dr. Crane said.

There are also practical issues limiting weekend care. Namely, the typical services such as physical therapy and case management are not routinely present on the weekends. As such, patients who could otherwise be discharged stay in their beds until Monday, when bed demands from the ED and OR increase dramatically. Bed capacity could be improved if hospitals can find ways to make services like testing and therapy available on weekends, and find surgeons and other consultants who will round on Saturdays and Sundays. That might mean hiring a physician’s assistant or other midlevel provider to cover.

Observation Units

Hospitals have also started making use of "observation" status for patients or adding observation units.

At Mary Washington Hospital, where Dr. Crane practices, a team of physicians, nurses, and administrators is designing a streamlined protocol for observation patients. Instead of the standard admission history and physical, an abbreviated assessment has been designed, incorporating use of the ED record and a brief assessment format. Consultations are reduced, and evidence-based pathways are being created for a variety of admitting diagnoses. Patients are treated as outpatients unless test results indicate they need to be moved to the inpatient side, and due to the reduced workload, nurses may be able to work comfortably with higher bed-to-nurse ratios.

The target is to hold patients for observation for 24 hours or less, Dr. Crane said.

Because observation patients are considered outpatients, insurers will pay the hospital less for the visit than if the patient is admitted, Dr. Pines noted, and it leaves the patient vulnerable to higher expenses than just an ED copay.

Another recent study in Health Affairs found that observation stays have been rapidly increasing – from 86.9 observation stays per 1,000 inpatient admissions in 2007 for Medicare beneficiaries to 116.6 in 2009 (Health Affairs 2012;31:1251-9). Of every 1,000 Medicare beneficiaries, 2 were under observation each month in 2007 and almost 3 were under observation each month in 2009. Meanwhile, inpatient admissions per 1,000 declined.

The Sharp Stick of Regulation

Voluntary efforts by hospitals may not be enough, said Dr. Sandra Schneider, former president of the American College of Emergency Physicians. Because hospitals are still paid for the patients who are boarded, they might not see the hidden costs of boarding, she said.

"We have to change that playing field if we want to get serious about [boarding]," Dr. Schneider said.

Among the game changers she cited are the increasing requirements for public reporting on quality measures, including those related to boarding.

Currently, hospitals get paid more by Medicare if they report certain inpatient quality measures. On the outpatient side, emergency departments report on the median time from ED arrival to ED departure for discharged patients and on patients who leave without being seen. In addition, it is now voluntary for hospitals to report on the average time patients spend in the ED before being admitted as an inpatient, and the average time patients spend in the ED after admission but before leaving the ED for their inpatient room.

Data from hospitals that have reported on these measures can be found on the Hospital Compare website.

The Joint Commission is also revisiting its standard on patient flow in the ED, which will go into effect in January 2013. Among other things, the commission is considering defining an episode of boarding as any case in which a patient remains in the ED 4 hours or more after a decision has been made to admit or transfer that patient.

Dr. Pines said that hospital administrators will be motivated both by public reporting imperatives and by Joint Commission standards. Dr. Crane, however, said that "until there are some significant incentives to moving patients upstairs in a timely manner, what’s going to drive senior executives is finance." He thinks that these new standards may help, but more incentives may be needed, such as penalties imposed if boarding limits are exceeded.

Australia, Canada, the United Kingdom, and other developed countries impose such limits and levy penalties.

Hospital Compare data – which will be more fully reported at the end of the first quarter of 2013 – “is going to show us once and for all where the median is and who are the outliers,” Dr. Schneider said. It’s hoped that the outliers will "realize they don’t just have a boarding problem – they have a serious boarding problem," she said.

"If not, then we may have to do what the rest of the world is doing."

Boarding has been a growing problem over the last decade and may worsen – at least in the short term – with the fuller implementation of the Affordable Care Act, according to experts who are calling for hospitals to implement proven remedies.

Hospital efficiency has suffered as institutions seek to cut costs while coping with a rising influx of uninsured and Medicaid patients. That financial pressure will not improve under health care reform, at least not initially, as millions more Medicaid patients are likely to seek care in the ED when they cannot access primary care, Dr. Jody Crane, emergency department faculty for the Institute for Healthcare Improvement, Cambridge, Mass., said in an interview.

Medicaid pay is already low, and an estimated 8 million more Medicaid patients will visit EDs annually after reform. In addition, as Medicare dials back its reimbursement to hospitals and physicians to help fund the Affordable Care Act, Va. That will put a squeeze on already tight hospital margins, he said.

"Every hospital is going to have to do the same or more with less," said Dr. Crane. Boarding – holding patients in the ED while they wait for admission to inpatient services – can be costly, reduces patient satisfaction, and has been shown to ultimately increase length of stay and mortality.

"Boarding in some hospitals is a capacity issue, but in others it’s also a management issue," Dr. Crane pointed out. Technical issues, including matching resources to the demand coming through the door, are also factors, he said.

"Ultimately, a coordinated effort is needed between the ED and the hospitalist to ensure quality transitions of care that maximize both health and financial outcomes," said Dr. Franklin A. Michota, director of academic affairs in the department of hospital medicine at the Cleveland Clinic. "Each hospital does need to analyze where their bottlenecks exist and whether a staffing solution is part of the answer. But the ED also needs to look at the accuracy and quality of their triage and their ability to adequately prepare the patient for the trip upstairs."

"For example," Dr. Michota continued, "sending a patient upstairs with sickle cell crisis and inadequate pain control just ties up the hospitalist unnecessarily and will delay the hospitalist in getting to the next new admission. Or failing to order a CT scan that would have sent a patient to the operating room and bypass the medical hospitalist altogether will again just delay getting to the next admission.

"Everything relies on everything else....the chain is only as strong as its weakest link."

Indeed, "the primary reason it’s a hard problem to fix is because it’s so multifactorial," said Dr. Jesse Pines, associate professor of emergency medicine and health policy at George Washington University in Washington, D.C.

What Works?

A recent study in Health Affairs showed that many hospitals still are not taking advantage of proven strategies to reduce boarding – among them, so-called smoothing of elective surgical schedules, active bed management by hospitalists, and the "full capacity protocol" that was developed by Dr. Peter Viccellio and his colleagues at the State University of New York at Stony Brook.

"This paper is another in a long series of wake-up calls about the dangerous practice of ‘boarding’ admitted patients in [emergency departments]," ACEP President Dr. David Seaberg said in a statement. "I just hope that hospital administrators and legislators smell the coffee. Their leadership is critical to changing the flow of patients from the front door of the emergency department to the inpatient floors of the hospital."

Emergency departments and hospitals can work together to find ways to improve efficiency, but several important ingredients are needed, Dr. Pines said. The Health Affairs article (2012;31:1757-66 [doi: 10.1377/hlthaff.2011.0786]) cites certain protocols that work, "but you need people to make them work," he said. "You need a strong leader in the ED who can get buy-in from the emergency group. ... You also need a supportive administration and medical staff to make it happen."

It is important to have a local quality improvement group whose members can look at the overall process by which patients get moved from the ED to inpatient services, and examine how patients are managed in the ED after they are admitted, Dr. Pines said. After the existing process is analyzed, hospital staff can identify and address the inefficiencies causing the delays.

The inefficiencies are highly particular to each facility, and often to each day and each shift in the ED and on inpatient wards, he said.

Staffing shortfalls – especially inpatient nursing staff – can be a major contributor to bottlenecks, Dr. Crane said. In response to financial pressures, many hospitals are reducing nursing staff, resulting in increased nurse-to-bed ratios. "That prolongs the inpatient length of stay," he said, because it leads to more work per nurse and more delays in admitting and discharging patients.

There has been a recent administrative trend toward real-time capacity management,which can be an effective way to accommodate the variation in admissions over time.. With this approach, if there is not an identified demand for nurses, they can be sent home or told not to come to work.This ability to change staffing levels according to real-time needs can be an effective way to accommodate the variation in admissions over time

Handoffs and Beds

Dr. Crane contends there are three specific elements to improving patient flow: the physician handoff, the nursing handoff, and bed efficiency.

The physician handoff can be made more efficient by optimizing the coordination between hospitalists and emergency physicians. Due to the high variation in arrival of admissions from the ED and the low numbers of admitting hospitalists at certain times, patients can queue in the ED awaiting admission orders, Dr. Crane noted.

So now, many emergency physicians write holding orders – which have an expiration time – until the patient can be admitted. Holding orders allow the patient to be moved out of the ED, Dr. Crane said. Until recently, emergency physicians have been reluctant to write holding orders, but this trend has reversed because it can be dramatically effective.ACEP now endorses the practice and notes that any associated risk is limited.

The unpredictability of admissions "creates all kinds of logistical nightmares handing off from the emergency department to the floor nurse," Dr. Crane said. Just adding more nurses is not necessarily the answer, and, in general, hospitals don’t have the money to add staff. Instead, hospitals need to better align existing resources and staff. For instance, nurses should probably not be transporting patients or cleaning rooms. That can be done with lower-priced and less-resource-intensive staff, Dr. Crane said.

Bed capacity is the third major element that hospitals should address to reduce boarding, according to Dr. Crane. Demand from the ED cannot be controlled, but on the inpatient side, hospitals can "smooth" the elective surgery schedule by moving more procedures to the middle and end of the week so that all the beds aren’t occupied early in the week. And that is not necessarily easy: "When you change block schedules, you get into cultural issues" with surgeons who do not want to have to see patients on the weekends, Dr. Crane said.

There are also practical issues limiting weekend care. Namely, the typical services such as physical therapy and case management are not routinely present on the weekends. As such, patients who could otherwise be discharged stay in their beds until Monday, when bed demands from the ED and OR increase dramatically. Bed capacity could be improved if hospitals can find ways to make services like testing and therapy available on weekends, and find surgeons and other consultants who will round on Saturdays and Sundays. That might mean hiring a physician’s assistant or other midlevel provider to cover.

Observation Units

Hospitals have also started making use of "observation" status for patients or adding observation units.

At Mary Washington Hospital, where Dr. Crane practices, a team of physicians, nurses, and administrators is designing a streamlined protocol for observation patients. Instead of the standard admission history and physical, an abbreviated assessment has been designed, incorporating use of the ED record and a brief assessment format. Consultations are reduced, and evidence-based pathways are being created for a variety of admitting diagnoses. Patients are treated as outpatients unless test results indicate they need to be moved to the inpatient side, and due to the reduced workload, nurses may be able to work comfortably with higher bed-to-nurse ratios.

The target is to hold patients for observation for 24 hours or less, Dr. Crane said.

Because observation patients are considered outpatients, insurers will pay the hospital less for the visit than if the patient is admitted, Dr. Pines noted, and it leaves the patient vulnerable to higher expenses than just an ED copay.

Another recent study in Health Affairs found that observation stays have been rapidly increasing – from 86.9 observation stays per 1,000 inpatient admissions in 2007 for Medicare beneficiaries to 116.6 in 2009 (Health Affairs 2012;31:1251-9). Of every 1,000 Medicare beneficiaries, 2 were under observation each month in 2007 and almost 3 were under observation each month in 2009. Meanwhile, inpatient admissions per 1,000 declined.

The Sharp Stick of Regulation

Voluntary efforts by hospitals may not be enough, said Dr. Sandra Schneider, former president of the American College of Emergency Physicians. Because hospitals are still paid for the patients who are boarded, they might not see the hidden costs of boarding, she said.

"We have to change that playing field if we want to get serious about [boarding]," Dr. Schneider said.

Among the game changers she cited are the increasing requirements for public reporting on quality measures, including those related to boarding.

Currently, hospitals get paid more by Medicare if they report certain inpatient quality measures. On the outpatient side, emergency departments report on the median time from ED arrival to ED departure for discharged patients and on patients who leave without being seen. In addition, it is now voluntary for hospitals to report on the average time patients spend in the ED before being admitted as an inpatient, and the average time patients spend in the ED after admission but before leaving the ED for their inpatient room.

Data from hospitals that have reported on these measures can be found on the Hospital Compare website.

The Joint Commission is also revisiting its standard on patient flow in the ED, which will go into effect in January 2013. Among other things, the commission is considering defining an episode of boarding as any case in which a patient remains in the ED 4 hours or more after a decision has been made to admit or transfer that patient.

Dr. Pines said that hospital administrators will be motivated both by public reporting imperatives and by Joint Commission standards. Dr. Crane, however, said that "until there are some significant incentives to moving patients upstairs in a timely manner, what’s going to drive senior executives is finance." He thinks that these new standards may help, but more incentives may be needed, such as penalties imposed if boarding limits are exceeded.

Australia, Canada, the United Kingdom, and other developed countries impose such limits and levy penalties.

Hospital Compare data – which will be more fully reported at the end of the first quarter of 2013 – “is going to show us once and for all where the median is and who are the outliers,” Dr. Schneider said. It’s hoped that the outliers will "realize they don’t just have a boarding problem – they have a serious boarding problem," she said.

"If not, then we may have to do what the rest of the world is doing."