Mitigating the Impact of Boarding on Patient Experience

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Boarding and Crowding: Boarding

Authors:

Yosef Berlyand, MD; and Jonathan D. Sonis, MD, MHCM, on behalf of the SAEM ED Admin and Clinical Operations Committee.

 

Overview

The nationwide crisis in emergency department (ED) crowding and inpatient boarding has continued to intensify, with negative consequences for patient care delivery, operational efficiency, and patient experience.1–4 Inpatient boarding has ballooned to unprecedented levels and has been labeled a public health emergency in an open letter to President Biden by the American College of Emergency Physicians.2

While many factors contributing to this crisis are beyond the control of frontline ED staff, there are several actionable items that can help mitigate the inevitable negative consequences of inpatient boarding on ED patient experience. We categorize these into four distinct categories:

  • Early Contact and Expectation-Setting
  • Periodic Updates
  • Distractions
  • Dedicated Patient Experience Liaison Rounding
Early Contact and Expectation-Setting

In our experience, ED patient experience improves with decreased door-to-clinician time, even with similar overall ED length-of-stay (LOS). Consequently, we recommend prioritizing early contact with patients and leveraging this initial touch point as an opportunity for expectation-setting.

It is important to ensure all role groups – physicians, advanced practice providers (APPs), nurses, and technicians – have an aligned set of expectations that they communicate to patients. We aim to set expectations early in the ED visit and frequently reiterate the message to prevent conflicting information. As part of our initial discussion with patients, we apologize for any prolonged wait times, introduce the expectation of hallway care, and reassure them that while their ED visit may be lengthy, we will address their concerns.

Sample script: "Hi, I'm Dr. X and I will be taking care of you in the emergency department today. I apologize for the long wait you've experienced. I want to assure you that we're initiating your care, and members of your care team will be by shortly to gather more information. Although we currently lack available rooms, we will transition you to a hallway stretcher as soon as possible to expedite your care. In the meantime, please don't hesitate to let me or any staff member know if there is anything we can do to make you more comfortable while you wait."

Periodic Updates

Frequent updates on the status of their work-up are vital to alleviate the anxiety associated with the uncertainty of an ED visit. Patients often feel disempowered and reliant on staff to progress their care, which heightens their anxiety. We have found that regular updates from any member of the care team can significantly alleviate this anxiety and improve patient experience.

Our realistic recommendation is that at least one member of the care team provides a brief update to the patient every hour. These updates can be as simple as informing the patient about the progress of their labs, their position in line for an x-ray or CT scan, or that their care is pending the results of a consultation. When regular in-person updates are not feasible due to staffing shortages, technology-based solutions such as automated event- triggered text messaging can help keep patients up to date on how their care is progressing. Above all, we aim for honesty and transparency. If asked for timeline estimates, we err on the side of caution, following the adage, "under promise, over deliver.”

Distractions

Investing in amenities within the ED can significantly enhance the patient experience. Measures such as providing reliable Wi-Fi for patient and caretakers, offering meals and snacks, decorating with artwork, and supplying electronic tablets for music, games, or other distractions can make the ED visit more comfortable.

Dedicated Patient Experience Liaison Rounding

In addition to frequent communication directly from the care team, we recommend that EDs invest in a dedicated patient experience liaison who is available to conduct rounds through the ED. This provides an additional layer of contact with patients and can identify opportunities for service recovery and further improve patient experience.

Variations of these interventions have been described within the patient experience literature.5,6 We selected these interventions for their perceived high-value and ease of implementation. At the core of all these interventions lie the fundamental values of empowering patients with information, maintaining transparency, and demonstrating empathy.

Interested Parties

Improving early contact, expectation setting, and providing frequent updates can be achieved with minor changes to ED workflow. To ensure uniform expectation setting, it is crucial to involve all role groups in the development and dissemination of suggested patient scripts.

Key stakeholders include ED physician leadership, nursing leadership, and APP leadership. By including leaders and representatives from all groups, implementation of these measures becomes easier to implement. Implementing distractions and a dedicated patient experience liaison requires funding and staff allocation, which would benefit from support by both ED and hospital leadership. For these programs to succeed, it's essential to involve key stakeholders in their implementation. This includes ED physician leadership, ED nursing leadership, and hospital quality and safety leadership. Establishing and maintaining a Patient and Family Advisory Council, comprising hospital staff, patients, and family members, facilitates the review of interventions and the provision of ongoing patient-centered feedback.

Key Points

  • Inpatient boarding in the ED has reached crisis levels nationwide and has negative implications for patient experience.
  • Early contact, introduction of the care team, realistic expectations about hallway care and care timelines, and periodic updates are essential for improving patient experience.
  • With support from hospital leadership, implementing programs to provide patient distractions and funding a dedicated patient experience liaison can significantly enhance patient experience.

 

Resources

  1. Baugh CW, Bohan JS. Estimating observation unit profitability with options modeling. Acad Emerg Med. 2008; 15:445-452.
  2. Baugh CW, Suri P, Caspers CG, et al. Financial viability of emergency department observation unit billing models. Acad Emerg Med. 2019; 26(1):31-40.
  3. Kelen GD, Schuelen JJ, Hill PM. Effect of an emergency department (ED) managed acute care unit on ED overcrowding and emergency medical services diversion. Acad Emerg Med. 2001; 8:1095-1100.
  4. Martinez E, Reilly BM, Evans AT, Roberts RR. The observation unit: a new interface between inpatient and outpatient care. Am J Med. 2001; 110:274-277.
  5. Ross MA, Aurora T, Graff L, et al. State of the art: emergency department observation units. Crit Pathw Cardiol. 2012; 11:128-138.
  6. Ross MA, Hockenberry JM, Mutter R, et al. Protocol-driven emergency department observation units offer savings, shorter stays, and reduced admissions. Health Aff (Millwood). 2013; 32:2149-2156.