NURS 6053 Week 3 Healthcare Issue Analysis Example

Emergency Department Boarding as a Hospital-Wide Problem: Local Impact and Two Strategies From the Literature

Student Name

College of Nursing, Walden University

NURS 6053: Interprofessional Organizational and Systems Leadership

Instructor Name

Month Day, Year

Emergency Department Boarding as a Hospital-Wide Problem: Local Impact and Two Strategies From the Literature

Introduction

Boarding is the practice of holding patients who have been admitted to the hospital in the emergency department while they wait for an inpatient bed. It is a national problem that has grown as hospital occupancy has risen and staffing has tightened. Boarding is not only an inconvenience: in a study of more than 41,000 admissions at an academic hospital, mortality and hospital length of stay rose as boarding time lengthened, with the longest boarders faring worst (Singer et al., 2011). This analysis follows the stressor into one composite 300-bed community hospital, summarizes two strategies from the literature, and judges which fits this building.

Local Impact

In the emergency department, boarding means that on most evenings between six and twelve admitted patients occupy emergency beds, some for more than twelve hours. Emergency nurses care for these inpatients, who need scheduled medications, reassessment, and sometimes continuous infusions, while also receiving new arrivals from triage. The ratios designed for emergency care do not fit inpatient work, and the nurses describe feeling that they are doing two jobs at once. Ambulance offload times lengthen when every bed is occupied, and patients in the waiting room wait longer to be seen, which increases the number who leave before evaluation.

On the inpatient units, the problem looks different. Discharges cluster in the late afternoon: patients whose physicians wrote discharge orders in the morning wait for final medication reconciliation, transport, or a ride home, and beds are cleaned and ready only in the evening. By then, the emergency department has accumulated its boarders. Inpatient nurses feel pressure to take admissions at shift change, when they are least able to receive them safely.

Every morning at eight, a bed huddle brings together the house supervisor, unit charge nurses, and case management. The huddle reports how many beds each unit expects to free and how many patients are waiting. It reports capacity accurately, but it does not change it: no one leaves the huddle with an action that makes a bed available sooner. The emergency department, inpatient nursing, hospital medicine, pharmacy, environmental services, and transport each control part of the flow, and no one controls all of it. That is why boarding looks like an emergency department problem but behaves like a hospital one.

Strategies From the Literature

Full-capacity protocol. Viccellio et al. (2009) described an institutional protocol at a suburban academic hospital with a large emergency department, under which admitted patients boarding in the emergency department were moved to inpatient hallways on the receiving units when the ED reached capacity, under defined conditions. The strategy redistributes the burden of crowding from one department to the whole hospital. In their four-year retrospective review, patients moved to hallway beds did not have worse outcomes than those admitted to standard beds. The setting was a high-volume academic center with a multidisciplinary team that designed the protocol and hospital leadership support.

Earlier-discharge initiative. Wertheimer et al. (2014) reported on an initiative on two medical units at an urban academic medical center to increase discharges before noon. Staff built a checklist of daily responsibilities, afternoon interdisciplinary rounds identified next-day discharges, and daily feedback on performance was provided. The percentage of patients discharged before noon rose substantially and stayed higher over thirteen months, the average discharge time moved earlier, and observed-to-expected length of stay fell without a significant change in readmissions. The setting was two medical units with engaged hospitalists and nursing leadership.

Application

The earlier-discharge approach fits this hospital better. The full-capacity protocol addresses the symptom, where boarders sit, and it depends on inpatient units accepting hallway patients, which requires space, staffing, and a culture this hospital's units do not currently have; moving boarders to hallways without addressing why beds free up late would shift the strain onto inpatient nurses. It is set aside for now. The earlier-discharge initiative addresses the cause identified in the local analysis: discharges that cluster in the afternoon because pharmacy, transport, and case management are not coordinated around a morning goal. It would need the cooperation of hospital medicine above all, since discharge orders and next-day planning depend on hospitalists' rounding, and a pilot would begin on the two medical units that generate most afternoon discharges. Pharmacy would need to complete discharge medication reconciliation the evening before for patients identified as likely next-day discharges, and transport and environmental services would need to shift some staff time to the late morning. The morning bed huddle would change purpose: instead of reporting expected discharges, it would confirm the actions each department owes to make those discharges happen before noon. The measures of success would be the hour at which beds become available and the number of evening boarders in the emergency department, tracked together so that the connection between the two problems stays visible.

Conclusion

Boarding is felt in the emergency department but produced across the hospital, by the timing of discharges and the separate clocks of the departments that control them. Treating it as a hospital-wide problem changes who is responsible for solving it, and it points the first strategy at the inpatient units rather than the ED.

References

Singer, A. J., Thode, H. C., Jr., Viccellio, P., & Pines, J. M. (2011). The association between length of emergency department boarding and mortality. Academic Emergency Medicine, 18(12), 1324-1329. https://doi.org/10.1111/j.1553-2712.2011.01236.x

Viccellio, A., Santora, C., Singer, A. J., Thode, H. C., Jr., & Henry, M. C. (2009). The association between transfer of emergency department boarders to inpatient hallways and mortality: A 4-year experience. Annals of Emergency Medicine, 54(4), 487-491. https://doi.org/10.1016/j.annemergmed.2009.03.005

Wertheimer, B., Jacobs, R. E. A., Bailey, M., Holstein, S., Chatfield, S., Ohta, B., Horrocks, A., & Hochman, K. (2014). Discharge before noon: An achievable hospital goal. Journal of Hospital Medicine, 9(4), 210-214. https://doi.org/10.1002/jhm.2154