Across nearly every hospital in the country, an entirely new unit has appeared. It’s one that nobody wanted and nobody knows exactly what to do with, but it’s there. You might call it purgatory, or a black hole, or limbo, or any number of other names, but thousands of patients are finding themselves there every day.
I’m talking, of course, about emergency department boarding: the practice of holding admitted patients in the ED—sometimes for days on end—when there are no inpatient beds available in the nursing units or there isn’t enough staff to care for patients in the inpatient setting.
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After the pandemic drove doctors and nurses from the profession at record pace and throttled capacities at hospitals around the country, the already existing ED boarder problem ramped into overdrive. Simply put, with fewer doctors and nurses on the floor, they don’t have the capacity for additional patients. That means that EDs, which rarely, if ever, shutter their doors, are left with nowhere to send patients that have been through the emergency room and have technically already been admitted to the hospital.
The patients, while they await transfer to an inpatient bed, a psychiatric facility, skilled nursing, or any other specialized unit, are still in the care of ED nurses, who now have more pressing patients to deal with. Through no fault of anyone directly involved, the quality of care can inevitably slip during those hours or days.
It’s a phenomenon with which I’m familiar from multiple perspectives. Not only did I spend the earliest part of my career in and out of emergency rooms as an ED and flight nurse, I’ve also experienced the agonizing limbo on the other end.
My father, who suffered from Lewy Body Dementia and experienced several grand mal seizures during the last few years of his life, made plenty of trips to the emergency room, and occasionally ended up as a boarder before being able to make it to the floor.
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Especially during Covid-19, when visitation wasn’t allowed, it was an unmooring experience for my father and a terrifying experience for my then-84-year-old mother, who was left without solid lines of communications with a care team, or even any real knowledge where her husband was.
Additionally, as patient wait times stretch, both before being admitted to the ED and while boarding, dissatisfaction grows, souring patients on their entire experience. In fact, studies have shown that longer wait times in the ED can have a dramatic effect on HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores, directly affecting Medicare reimbursements and hospital revenue.
On a macro scale, the phenomenon is so disruptive and harmful that nearly three dozen professional medical associations sent a letter to The White House last year calling boarding “its own public health crisis” and imploring the administration to take steps toward solving it.
Given that the labor shortage driving the crisis is unlikely to abate in the near term, however, it’s imperative that hospitals move quickly to address the issue. And some of the most meaningful actions come through simple communication, often via the same rounding mechanisms hospital leaders already have in place.
Implementing boarder, waiting room, and general ED rounding, while requiring slight tweaks from the usual patient rounds, results in similar benefits: ensuring patients feel heard, keeping them better informed and in control over their own care, and unearthing problems and areas of opportunity in the moment to enable fast operational and clinical decision making.
Here are some of the key considerations for implementing effective ED rounding:
Start a timer: When a patient is admitted from the ER to the hospital, a timer starts. And every minute that goes by after that admission order before a patient is actually physically moved to their next destination adds uncertainty and discontent. In many hospitals, that time frame simply isn’t even tracked. But if the admission order can trigger a timer that alerts ED staff at certain intervals after that admission time—every two hours, for example—staff members can round on the patient to ensure they don’t feel forgotten.
Set priorities: Similar to how emergency departments triage patients based on condition, it’s important to prioritize rounds based on need. Emergency staff with limited rounding resources should focus first and foremost on boarders, but it’s also critically important to have a pulse on patients who haven’t been seen yet to prevent walkouts. During periods with lengthy wait times in the waiting room, it’s important for nurse and hospital leaders to also be in steady communication with patients in the waiting room. Finally, if time allows, patients in the ED treatment area should also be rounded on before being discharged from the emergency department.
Know your patients and personalize rounds: At the start of a rounding encounter, it’s important to check rounding history for each patient to glean any non-clinical insights. By coming prepared with information from previous encounters—and being ready to act on any previously expressed patient preferences—hospital staff can lead with compassion, make patients feel seen, and ask better, more personalized questions. This is the area in which ED rounding can build cumulative benefits over time: every round is an opportunity to gather more information and improve care during future interactions.
Be transparent and thorough: Boarders are in a position of particular uncertainty. Every boarder round should be treated as a bidirectional flow of information. While it’s important to gather information from boarders, it’s equally important to provide them with accurate information about their next steps. Any delays should be explained transparently and, to the degree possible, rounders should explain what the patient can expect as they move to the next step of their care journey.
The ED boarding crisis is not one that’s going to be solved overnight. The new unit that nearly every hospital finds itself saddled with is emblematic of much deeper, more systemic issues within the healthcare system at large. But left to continue unchecked, it will only engender wider discontent, decrease patient satisfaction, and ultimately lead to worse outcomes.
That doesn’t mean, however, that the boarder crisis experience can’t be improved—it just takes a bit of operational tweaking, intention, compassion, and communication.
Joy Avery, MSN, RN is SVP of Clinical Strategy at CipherHealth. She brings 37 years of expertise in clinical practice, healthcare operations, capacity management, and operationalizing enterprise command centers in dozens of healthcare systems across the US and UK. Prior to moving into the healthcare IT space, Joy had the opportunity to deliver patient care in a wide range of roles at North Mississippi Medical Center in Tupelo, MS, including Chief Flight Nurse, Trauma Program Manager, and Director of Specialized Clinical Services responsible for transfer center, patient throughput, bariatric services, and nursing leadership programs. In her role at CipherHealth, Joy serves as a clinical SME, assisting both her Cipher peers and customer partners in improving the patient, family, and staff experience. Joy is passionate about improving patient outcomes and access across the care continuum.
