ED to Wards: Beating the Boarding Problem

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."