ACEP research investigator recommends penalizing hospitals for boarding (scroll down)
Mary Crotty
Prolonged Stays in Emergency Department Translate Into Long Stays in Hospital
Fran Lowry
October 6, 2009 (Boston, Massachusetts) — A prolonged stay in the emergency department (ED) is associated with a longer stay in the hospital for patients who get admitted, according to new research presented here at the American College of Emergency Physicians 2009 Scientific Assembly.
Such prolonged stays or "boarding" likely contribute to multibillion dollar increases in medical-care costs, said Alan Heins, MD, from the University of South Alabama in Mobile.
Excessively long stays in EDs are an increasing — and serious — problem for American hospitals, and are actually harmful for patients, some studies show. However, no population-based studies have directly examined the public health impact of ED boarding, Dr. Heins said.
He and his coinvestigators studied the epidemiology of prolonged ED stays and their effects on hospital length of stay and in-hospital mortality in a secondary analysis of data from the 2006 National Hospital Ambulatory Medical Care Survey.
The study cohort consisted of 15,207,497 patients who were admitted to hospital, 2,242,547 of whom were admitted to an intensive care unit, out of more than 119 million ED visits in 2006.
Despite the fact that the severity of illness was similar, patients who stayed longer in the ED stayed longer in the hospital than patients with shorter ED stays.
Compared with patients who stayed in the ED for less than 3 hours, patients who stayed in the ED for 3 to 6 hours had a hospital length of stay that was 0.43 days longer, patients who stayed in the ED for 6 to 9 hours had a hospital length of stay that was 0.91 days longer, and patients who stayed in the ED for more than 9 hours had a hospital length of stay that was 0.55 days longer.
When patients in the intensive care unit were analyzed, a similar trend was seen. Those in the 6- to 9-hour and the more than 9-hour groups had hospital length of stays that were 0.74 and 1.33 days longer, respectively, than the patients who stayed in the ED for less than 3 hours.
The analysis also showed that admitted patients with lower initial triage priority experienced longer stays in the ED; females, blacks, and self-pay patients were held in the ED for long periods more frequently than were males, whites, and privately insured patients; and patients with more acute triage assessments and patients recommended for critical care admission were more likely to die in the hospital.
However, contrary to previous studies, prolonged stays in the ED did not contribute to worsened survival.
"People who stayed longer in the ED stayed longer in the hospital, even if everything else was pretty much equal. The implication is that it was probably unnecessary for them to stay that much longer because they weren’t any sicker than the people who got their bed more quickly," Dr. Heins told Medscape Emergency Medicine.
Asked what effect he would like to see the results of his study have on current practice, Dr. Heins replied that a "pretty simple" step toward quality and patient-safety improvement would be to penalize hospitals for boarding patients in the ED.
He cited the National Health Service in the United Kingdom, which has started doing just that. "They now have a rule that 95% to 98% of patients must be out of the ED within 4 hours. If not, the hospitals get in trouble. In our survey, there were patients who were in the ED for more than 9 hours. That would now be unacceptable in England. The Centers for Medicare and Medicaid Services could make a rule that they won’t pay hospitals if people stay too long in the ED. Or if there is too long a wait in the ED, then the hospital could be at risk for not being accredited."
Commenting on the study for Medscape Emergency Medicine, Jesse Pines, MD, from the Hospital of the University of Pennsylvania in Philadelphia, said there could be several reasons for the findings.
"When patients spend a lot of time in the ED, their inpatient evaluation and treatment doesn’t typically start until they actually get to a hospital floor, so the delays in treatment they experience might contribute to longer overall hospitalizations for these patients," he said.
Longer ED stays could also mean that the hospital is less efficient overall, he added. "Hospitals that tend to board in the ED for longer periods of time tend to operate less efficiently. In certain hospitals, it just takes longer to get everything done. I think it’s an interesting study and adds to the growing literature that ED boarding is associated with negative outcomes."
Dr. Heins and Dr. Pines have reported no relevant financial relationships.
American College of Emergency Physicians (ACEP) 2009 Scientific Assembly: Abstract 058. Presented October 5, 2009.
