The practice of emergency medicine/brief research reportA Pilot Study Examining Undesirable Events Among Emergency Department–Boarded Patients Awaiting Inpatient Beds
Introduction
As a consequence of hospital crowding, many patients are spending extended amounts of time “boarding” in the emergency department (ED) as they wait for hospital beds to become available. Because ED care focuses more on stabilization and diagnosis, EDs may be less well equipped than inpatient units to provide inpatient level of care to boarders. In fact, the Institute of Medicine reported that boarding not only compromises the patient's experience but also enhances the potential for errors, delays in treatment, and diminished quality of care.1 Although there are a number of other such studies examining the effects of hospital crowding,1, 2, 3, 4 relatively few have examined ED boarding. Although studies have shown that longer ED length of stay or boarding times are associated with longer hospital length of stay, higher rates of recurrent myocardial infarction, and increased mortality, few studies have directly examined the quality of care for ED boarders at the individual patient level.5, 6, 7 We conducted this pilot study to explore the epidemiology of undesirable events that occur while patients board in the ED.
Section snippets
Study Design
This was a retrospective study designed to describe the characteristics of boarders and serve as a pilot project for a larger study examining the frequency of undesirable events among ED boarders. The institutional review board of the participating institution approved this study.
Setting
The study took place at a Level I trauma, tertiary, urban teaching hospital. No explicit policy exists as to how boarder patients are managed, ie, whether holding orders are written or how long it should be before
Results
During the 3 days we studied, 162 patients were admitted. Of these 162 patients, 151 charts were reviewed; 11 (6.8%) could not be located after multiple attempts.
Table 1 provides characteristics of patients in the study and the percentage who experienced an undesirable event while boarded. More than a quarter of patients had 1 or more undesirable events. Patients who were older than 50 years, had Charlson comorbidity scores greater than zero, or boarded greater than 6 hours were more likely to
Limitations
As with many pilot projects, this project had several limitations. First, our sample size was relatively small. Hence, the number of preventable adverse events observed was limited. However, given that the purpose of the pilot study was to begin to examine undesirable events among boarding patients at a granular level, the study gives insight into how to power future studies.
Because our study collected data only while patients boarded in the ED, it lacks a counterfactual comparison with
Discussion
Despite its limitations and exploratory intent, this study demonstrates several epidemiologic points: (1) more than one fourth of patients experienced an undesirable event while boarding, (2) 3.3% of boarded patients experienced a preventable adverse event, and (3) patients who had undesirable events while boarding were older and had more comorbidities.
The study shows that 27.8% of patients had an undesirable event while boarding, although this was largely attributable to missed home
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Supervising editor: Robert L. Wears, MD, MS
Author contributions: SWL, JAG, and JSW conceived the study and designed the study. SWL performed initial chart abstraction. SHT and AGH performed secondary implicit chart review. SWL managed the data. SHT provided statistical advice. SWL drafted the article, and all authors contributed substantially to its revision. SWL takes responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.
Publication date: Available online March 13, 2009.
Reprints not available from the authors.