A guide to successfully navigate ED boarding

Overwhelming, chaotic, inefficient, dysfunctional — all four words appear throughout a recent report describing the nationwide challenge of emergency department boarding published by the American College of Emergency Physicians. 

ED boarding can be caused by a variety of factors, including healthcare workforce and staffing challenges, transparency and reimbursement issues with payers, inadequate resources for mental healthcare, barriers to discharging patients to other inpatient services and more, the report outlines.

When ED boarding occurs and capacity is strained forcing a gridlock of available beds, a million scenarios can occur, but what counts, emergency medicine leaders told Becker's, is truly the foundation and culture upon which strategies are built to keep things running smoothly during these times that can feel dysfunctional, chaotic and overwhelming.

"Boarding is causing widespread dysfunction, and we feel it every day," Aisha Terry, MD, the president-elect of the ACEP stated during a presentation of the report. "It won’t happen overnight, but we are one step closer to solutions because we are coming together."

The report proposes a list of six solutions including payment incentives, developing reportable metrics on ED boarding and capacity that are publicly available, lift Certificate of Need processes in some states that limit ability to expand capacity, and find alternatives for patients in need of psychiatry services and other basic care outside of the ED. 

While some of the proposed solutions will inevitably take time for hospitals and health systems to recognize, adopt and implement, here are the game plans three emergency medicine experts are using to keep teams organized during ED boarding strains in the interim.

Responses have been lightly edited for clarity and brevity:

Neel Vibhakar, MD, Senior Vice President and Chief Medical Officer at the University of Maryland Baltimore Washington Medical Center, and the Associate Chief Clinical Officer for the University of Maryland Medical System: Every morning, our hospital sets the tone for the organization for the day with communication. So, we have a very good sense of what to expect based on what has happened the night before, or the day before, of how crowded things are and if capacity will be difficult or challenging. Our initial huddle really sets off a string of conversations and actions for that day, or a game plan, so to speak. 

We really do make sure that the entire organization is aware of the challenges that we are seeing and feeling in the ED. The ability for us to decompress and allow for efficient patient movement doesn't only live in the emergency department, it is really an all hands-on deck approach to address these challenges. With that, we have enacted several criteria that need to be met, in which we go into a certain service levels. Within each service level, each of our department leaders have tasks that each consider doing to help us out in creating space, creating activity and improving the number of discharges that we have for that day. 

It really takes everyone in the organization, every department, realizing that they can have an impact on patients by enacting their own protocols for a surge plan to help us move patients through efficiently.

Jared Ross, DO, emergency medicine physician, former Captain of the Disaster Action Team for the American Red Cross, current President and CEO of EMSEC, an EMS consulting service for hospitals and health systems: A major contributor to our current ED boarding crisis is the national mental health crisis. Due to a severe lack of inpatient beds, patients with suicidal ideation and acute psychosis are spending days in the emergency department tying up beds. Not only do these patients take capacity away from the ED, but they also take nursing and tech staff resources away, as The Joint Commission standards require that they have a 1:1 sitter at all times. The situation is even worse with pediatric and dual diagnosis (mental health and intellectual disability) patients, who can spend weeks or more waiting for psychiatric bed placement.

There are creative short-term solutions that can help alleviate some of this pressure while we work on increasing psychiatric bed availability and building dedicated psychiatric emergency departments. This can include placing a provider in triage to discharge low-acuity patients, comingled areas for patients pending laboratory or radiological results, and potentially moving boarding patients out of the ED to disused areas of the hospital.

Angela Kaiser, DNP, RN, former nurse leader with Memorial Health System in Springfield, Ill., currently a Clinical Consulting Advisor for healthcare staffing company VitaWerks: When facing capacity challenges in the Emergency Department, my game plan revolves around a multi-faceted approach aimed at mitigating bottlenecks, optimizing resources, and maintaining high standards of care.

First and foremost, proactive planning is key. Establishing clear protocols and workflows for managing high capacity situations is essential to ensure that all staff members are aligned and prepared to respond promptly. This includes developing comprehensive triage guidelines, streamlining admission processes, and implementing strategies for rapid patient turnover.

Communication is also paramount. Keeping lines of communication open among ED staff, hospital administrators, and other stakeholders enables us to coordinate efforts effectively and make informed decisions in real-time. Regular briefings, huddles, and debriefings help keep everyone informed, engaged, and focused on the common goal of providing timely and efficient care to patients.

Training and education play a crucial role in ensuring that staff members are equipped with the knowledge, skills, and resources necessary to navigate high capacity situations with confidence and competence. This includes ongoing training on triage protocols, patient flow management, and effective communication strategies, as well as cross-training initiatives to enhance flexibility and adaptability among team members.

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