Health policy and clinical practice/editorial

The Emergency Department Crowding Paradox: The Longer You Stay, the Less Care You Get

Hospital crowding and emergency department (ED) boarding are large and growing problems. To date, there has been a paucity of information regarding the quality of care received by patients boarding in the ED compared with the care received by patients on an inpatient unit. We compared the rate of delays and adverse events at the event level that occur while boarding in the ED vs while on an inpatient unit.

This study was a secondary analysis of data from medical record review and administrative databases at 2 urban academic teaching hospitals from August 1, 2004, through January 31, 2005. We measured delayed repeat cardiac enzymes, delayed partial thromboplastin time level checks, delayed antibiotic administration, delayed administration of home medications, and adverse events. We compared the incidence of events during ED boarding vs while on an inpatient unit.

Among 1431 patient medical records, we identified 1016 events. Emergency department boarding was associated with an increased risk of home medication delays (risk ratio [RR], 1.54; 95% confidence interval [CI], 1.26-1.88), delayed antibiotic administration (RR, 2.49; 95% CI, 1.72-3.52), and adverse events (RR, 2.36; 95% CI, 1.15-4.72). On the contrary, ED boarding was associated with fewer delays in repeat cardiac enzymes (RR, 0.17; 95% CI, 0.09-0.27) and delayed partial thromboplastin time checks (RR, 0.54; 95% CI, 0.27-0.96).

Compared with inpatient units, ED boarding was associated with more medication-related delays and adverse events but fewer laboratory-related delays. Until we can eliminate ED boarding, it is critical to identify areas for improvement.

Boarding of inpatients in the Emergency Department (ED) has been widely recognized as a major contributor to ED crowding and a cause of adverse outcomes. We hypothesize that these deleterious effects extend to those patients who are discharged from the ED by increasing their length of stay (LOS).

This study investigates the impact of boarding inpatients on the ED LOS of discharged patients.

This retrospective, observational, cohort study investigated the association between ED boarder burden and discharged patient LOS over a 3-year period in an urban, academic tertiary care ED. Median ED LOS of 179,840 discharged patients was calculated for each quartile of the boarder burden at time of arrival, and Spearman correlation coefficients were used to summarize the relationship. Subgroup analyses were conducted, stratified by patient acuity defined by triage designation, and hour of arrival.

Overall median discharged patient ED LOS increased by boarder burden quartile (205 [95% confidence interval (CI) 203–207], 215 [95% CI 214–217], 221 [95% CI 219–223], and 221 [95% CI 219–223] min, respectively), with a Spearman correlation of 0.25 between daily total boarder burden hours and median LOS. When stratified by patient acuity and hour of arrival (11:00 a.m.–11:00 p.m.), LOS of medium-acuity patients increased significantly by boarder burden quartile (252 [95% CI 247–255], 271 [95% CI 267–275], 285 [95% CI 95% CI 278–289], and 309 [95% CI 305–315] min, respectively) with a Spearman correlation of 0.18.

In this retrospective study, increasing boarder burden was associated with increasing LOS of patients discharged from the ED, with the greatest effect between 11:00 a.m. and 11:00 p.m. on medium-acuity patients. This relationship between LOS and ED capacity limitation by inpatient boarders has important implications, as ED and hospital leadership increasingly focus on ED LOS as a measure of efficiency and throughput.