Many emergency departments got a brief reprieve from boarding during the COVID-19 pandemic, but most are seeing a return to prior volumes and, with it, the problem of boarding. While boarding is most acutely felt in emergency departments, the solutions to boarding are on the inpatient side, and they are not simple. They often require cultural and operational changes.

Improving the boarding burden is, in large part, predicated on bed capacity and efficient hospital-wide throughput. Decreasing the time patients spend in the emergency department after the decision has been made to admit does not just help us. Minimizing boarding is associated with a downstream positive effect on decreasing the entire inpatient length of stay (LOS).^1,2 This is important when trying to align the inpatient and ED efforts. Moreover, delays in getting patients to inpatient beds have been associated with a variety of adverse events.³ Lengthy inpatient stays and discharge delays can lead to admission inefficiencies, resulting in a vicious cycle of delays in throughput.

Understanding Discharge Delays

Discharge delays occur when hospitalized patients remain in an inpatient bed beyond what is medically necessity. Discharge delays have negative consequences for both patients and hospitals. Just as the boarding of admitted patients in the emergency department is fraught with patient safety issues and suboptimal care delivery, discharge delays create comparable problems in the inpatient care continuum. With hospitals running at high occupancy, delayed discharges contribute to a host of negative conditions:⁴

• Delayed discharge is associated with increased mortality and infections and reductions in mobility and daily activities.⁵
• Delayed hospital discharges of older patients are common and associated with significant cost.⁶

However, addressing discharge delays is possible and can have benefits for the whole hospital system.

• New studies are helping to identify patients at risk for delayed discharges.^7,8
• Discharge delays can often be remedied with care teams and managers.⁹
• Discharge timeliness has a positive impact on hospital crowding and ED flow.¹⁰

Boarding occurs due to demand-capacity mismatch, sometimes referred to as disequilibrium. Hospitals have staffed beds available for a finite number of patients, and they are occupied predominantly by ED patients, transfers into the facility, and procedural admissions. For most inpatient beds, there is already a new patient immediately ready for bed placement when the current occupant is discharged. Hospitals often operate under over-capacity conditions. When demand and capacity are so tightly matched, even the slightest delay in discharging a patient results in ED boarding.

Figure 1 shows a typical admission and discharge disequilibrium curve during a 24-hour cycle. The red demonstrates admissions, which occur even after midnight from the emergency department. There are generally no discharges after midnight. The 5 a.m. admission spike is artifactual and represents data being populated with procedural admissions. The gray curve represents discharges or open beds by hour. Note that in this typical example, capacity for patients admitted after midnight does not match demand until after 2 p.m. This correlates to high arrival times for the emergency department, which is already in its own state of disequilibrium stemming from both from a high volume of arrivals and admitted patients not moving upstairs. In addition, a surge in discharges means a surge in “dirty beds,” which creates another mismatch: Environmental services/housekeeping typically scales back staffing at 3 p.m., just when emergency departments need them the most. This results in wasted inpatient bed capacity as rooms are empty but not clean.