About half of Kent Hospital’s 50 emergency department beds are occupied by patients who are waiting for an inpatient bed.
The hospital in Warwick, Rhode Island, redesigned its emergency department to accommodate a persistently high number of these patients stuck in hospital limbo, referred to as emergency department boarding.
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Emergency department boarding strains limited hospital capacity, contributes to nurse and physician burnout and can lead to unhappy patients and worse care outcomes. Health systems are trying to expedite the discharge process to free up inpatient beds, more efficiently transfer patients in the emergency department to other hospitals and work closely with community health and social workers to head off emergency department visits.
Kent Hospital set up makeshift pods in its emergency department that are functioning as inpatient units, converted its CPR room, placed beds in the hallway and outfitted recliner chairs to make room for admitted patients who can wait for hours, days or even weeks until an inpatient bed becomes available.
“We changed the emergency department layout from how it was initially conceived so we are using every open space,” said Dr. Daren Girard, chief of emergency medicine at the Care New England hospital. “This is the new normal.”
Kent resembles many hospitals throughout the country trying to manage extended-stay emergency department patients.
“Boarding is one of the top problems facing the entire emergency care system in the U.S.,” said Dr. Benjamin Abella, chair of emergency medicine at Mount Sinai Health System in New York City. “It affects everything we do, certainly our ability to appropriately take care of our patients.”
Longer discharge processes create a bottleneck in the emergency department. Fewer emergency department boarding patients can move to inpatient beds when hospital patients stay for longer than necessary.
These backlogs create scenarios where patients that should be in inpatient settings are treated in emergency departments that may not be optimally designed or staffed for their care, often frustrating clinicians and patients.
“Patients get frustrated as they are sitting on a gurney in a noisy emergency department potentially for days,” Abella said. “As much as we try our best, care is not delivered in the same way because we are not inpatient care teams.”
Patients waited an average of 12.8 hours in an emergency department for an inpatient bed in 2023, according to the latest national data from Sg2, a data analytics company owned by group purchasing organization Vizient. That wait time has stayed relatively consistent since the COVID-19 pandemic, when the number of patients and wait time for emergency department boarders spiked.
The pandemic increased post-acute provider staff turnover, limiting capacity. Most insurers have also steadily ramped up prior authorization requirements, potentially keeping a patient waiting in an inpatient bed for longer than necessary as clinicians wait for insurers to sign off on a skilled nursing facility placement, health system executives said. Patients are also coming to hospitals sicker, and some don’t have transportation or care support at home, requiring them to stay at hospitals longer.
“Social factors are one of the primary drivers,” said Sameer Shah, president of Mount Sinai Hospital, a safety-net hospital in Chicago. “Families might not be ready to send them home, patients may be homeless or they may not have transportation. There are whole other issues with the uninsured and undocumented.”
Mount Sinai Hospital has partnered with community organizations, which send staff to the hospital to help patients find housing. The hospital dispatches social workers throughout the facility, coordinating follow-up calls with patients after they are discharged and visiting their homes, Shah said. Mount Sinai Hospital and its Sinai Urban Health Institute also provide transportation, nutrition assistance and job placement services, which have improved capacity and limited unnecessary hospital visits, he said.
Hospitals like Mount Sinai are trying to get a better handle on transfers by working more closely with affiliate hospitals. As a result, emergency boarding times have dropped as patients are moved from a full hospital to one with some available beds, executives said.
Washington set up a statewide coordination center during the COVID-19 pandemic to try to improve the patient transfer process and keep tabs on hospital capacity levels. Each day, hospitals send the Washington State Department of Health their number of available inpatient, intensive care unit and other beds.
The center has helped improve communication across hospitals, reduce transfer times and limit emergency department boarding times, said Darcy Jaffe, senior vice president for clinical excellence at Washington State Hospital Association.
“It’s the glue that holds a very fragile system together across our state because there is no extra capacity,” she said.
MyMichigan Health started a transfer request pilot program in December, where a hospitalist works with clinicians at MyMichigan facilities to prioritize hospital-to-hospital transfers and streamline the process, said Rachel Aultman, vice president of post-acute care at the Midland, Michigan-based system.
The health system also appointed a throughput coordinator, who has helped reduce excess days by half a day per patient discharge since they were appointed in January 2023, she said. The coordinator will flag certain barriers for patients’ pending transfers to skilled nursing facilities, such as the use of certain medications or specialist consultations that can delay discharges, Aultman said.
“These strategies have helped, but we quickly realized that the capacity we created was gobbled up as quickly as we created it,” she said.
Discharge hurdles are magnified on weekends, when there are typically fewer hospital and skilled nursing facility staff. Busy flu seasons, like this year’s, can also crimp hospital operations.
"Health systems have to understand this is not an emergency department flow problem, it takes the entire system to change design, process and structure," said Dr. Jason Wilson, founding chair of the emergency medicine department at USF Health Morsani College of Medicine in Florida.
Mount Sinai Health System has been offering more virtual care to ease emergency department and inpatient capacity constraints, as well as expanding its hospital-at-home program, which aims to provide hospital-level care where patients live.
Providence has also used telehealth to improve efficiency, said Dr. Darryl Elmouchi, chief operating officer for the Renton, Washington-based system. That strategy has been particularly helpful in rural hospitals, where specialists can consult clinicians via video to speed up the discharge process, he said.
Still, progress is incremental, Elmouchi said.
“It’s like we are running up a hill that keeps getting steeper,” he said.
