Eighteen months ago, an Atrium hospital in High Point, N.C., had thousands of hours in emergency department boarding. By implementing multiple strategies, the hospital has significantly reduced this burden, according to Paula Correa, DNP, RN.
Dr. Correa, chief nursing officer of Atrium Health Wake Forest Baptist—High Point Medical Center, told Becker’s that, between late 2023 and early 2024, the hospital had the highest ED boarding stats compared to five Atrium Health hospitals in its market.
“The most dangerous place to be in a hospital is in the ED waiting room, because [patients]could be really sick and they’re in the hospital but they’re not back getting care, and that’s a really dangerous place to be,” Dr. Correa said. “So we’ve really focused on [moving] patients out of the waiting room into care spaces so that they can get the care that they need and they feel like they’re moving through a process.”
ED boarding is the practice of holding patients in the ED, often in hallways, when they require admission but no inpatient beds are available. It endangers patient safety and increases healthcare costs.
High Point Medical Center has 351 licensed beds, and 276 are currently operational. The hospital’s census can reach up to 270 in the winter before the respiratory virus season tapers off, Dr. Correa said, but High Point is still averaging between 240 and 260. Yet despite having an unusually high census, High Point has dramatically mitigated boarding.
“Today, we don’t have any boarders in our ED,” Dr. Correa told Becker’s in a June 2 interview. “We have open beds that are staffed, and our census is still well into the 200s, which, at this time of the year, is unheard of for us. We usually would be [at] 180s, 190s. Our volumes are high for what we’re used to, and yet we still have managed to keep space open and not have any boarders today.”
How they did it
High Point Medical Center executed several strategies to reduce ED boarding, including the creation of a 12-bed clinical decision unit, revising triage staffing protocols, and implementing a “whole house solution” to ensure the right patient is in the right bed, Dr. Correa said.
The clinical decision unit was partly modeled after a sister hospital’s CDU. The 24/7 unit, which is staffed by an APP and inpatient nurses, pulls low-acuity patients out of the ED and places them in their own room. For example, a patient with generalized stomach pain will receive a scan in the ED before moving to the CDU for a few hours.
It’s highly protocolized and less intense than observation, Dr. Correa said. Patients are there for fewer than 24 hours and, depending on their results, might be admitted or referred to a specialist for a follow-up outpatient visit.
“You would be shocked at how just 12 beds can decant the emergency department while there’s still tests being run on these patients,” she said. “They’re still getting the care that they need, and they have a dedicated APP and nursing staff up there.”
Across the hall from the clinical decision unit is a six-bed transitional care unit for any patient in transition, such as someone from the ED waiting on an inpatient bed or a patient from the post anesthesia care unit waiting for a bed to be cleaned. To improve efficiency, nurses complete patients’ admission assessments, which can take up to an hour, in the TCU.
In addition to these units, the medical center placed an APP in triage to ensure care begins earlier and will put a second triage nurse during high-volume times. Staff will also scout out rooms that need to be turned over in case a patient is discharged but the computer doesn’t yet reflect the discharge.
Dr. Correa also created a “Right Patient, Right Bed” initiative, which she said “changed the game for bed placement and [has led to] statistically significant decrease in codes and rapids from the floor.”
Less than 2% of High Point patients leave without being seen, according to Dr. Correa. To achieve this dramatic reduction in ED boarding while ensuring high quality care, she recommended hospital leaders lean into creativity.
“I know that everybody doesn’t have a clinical decision unit or transitional care unit. Some people don’t have space, but get creative in the ways that you can maximize,” she said. “How is your house operations flowing? Are you sending people out to check the doors and make sure people are gone? Do you have your medical team on board? Have you talked to your hospitalist? What about your [chief medical officer]?
“There are ways that you can do this work,” Dr. Correa added. “It won’t always be comfortable, but if you want to get your borders down, you’ve got to churn the patients faster in a way that still keeps them safe … Continue to work the issue, because we all see it, but it doesn’t mean that there’s not a way out of it.”
