Every emergency physician has, at one time or another, scanned the emergency department and noticed that patients who should be headed to other departments for care are still there. The time from the decision to admit a patient until the inpatient unit accepts the patient for the transition of care is called “boarding,” and its impact on patient care has been discussed in a previous ACEP Now article.¹

ED leaders have been handed significant responsibility for ED processing, including admitted patients, and must carefully manage the department’s resources. What hasn’t been discussed is the fact that the overall effect of inpatient boarding on an emergency department’s bottom line has been vastly underestimated.

The Emergency Department Benchmarking Alliance (EDBA), a not-for-profit organization that offers resources to ED leaders, has collected data on ED performance measures that provide insight into the operational and financial impact of ED boarding. In the data, EDBA discovered clear associations between boarding time, average length of stay (LOS), and the rate at which patients leave before treatment is complete.

The EDBA data on boarding are from 1,195 emergency departments participating in EDBA data surveys completed in 2014 and 2015. The results have been compiled into Table 1.

A Matter of Time

According to respondents, the median length of ED boarding for patients going to an inpatient unit averaged 109 minutes across all emergency departments. Because some departments have boarding times substantially longer than 109 minutes, the cohorts were divided into three sets based on the actual boarding times.

The EDBA found a substantial effect of boarding on the LOS of all patients, including those who were treated and released. There is a profound effect on the ultimate marker of patient dissatisfaction: leaving the emergency department before treatment is complete.

The emergency departments that slowly offload admitted patients, with a boarding wait time of 240 minutes or more, are presented on the second row of Table 1. These departments, “constipated” with too many boarding transfers kept waiting, have more than double the number of patients who leave before treatment is complete compared to the average department, and they have an average of 233 boarding hours per day in the department. Ranging in volume from 33,000 to 130,000 patients per year, these emergency departments served an average of about 70,000 patients annually. The average boarding time per patient was almost six hours, and the overall LOS for admitted patients was almost 10 hours. In constipated departments, more than 5 percent of patients left—about 10 per day.

Contrast this to the emergency departments that processed admitted patients at a higher rate than the mean in the data survey, presented on the third row of Table 1. These departments had a lower walkaway rate, with a dramatically reduced ED boarding load per day. Ranging in volume from 18,000 to 119,000 patients per year, these emergency departments served an average of about 57,000 patients annually. The average boarding time per patient was about 2.5 hours, and the overall LOS for admitted patients was 6.5 hours. They still lost about five patients each day.

The emergency departments that processed admitted patients at a faster rate than the mean are represented on the fourth row of Table 1. These departments had a walkaway rate lower than the universe of all emergency departments and had dramatically reduced ED boarding hours per day. The departments ranged in annual volume, up to 128,000 patients. The average boarding time per patient was about 92 minutes, and the overall LOS for admitted patients was less than 3.5 hours. They averaged only 2.4 patients per day who left before treatment was complete.

Financial Implications

Using some revenue estimations based on Table 1 data, the financial impact of boarding on the emergency department is clear.

Table 1. Boarding Time and Performance Measure

The Medical Expenditure Panel Survey (MEPS) is a publicly available, ongoing, national dataset from the Agency for Healthcare Research and Quality that presents information on health care use and expenditures, including charges for ED service.² It uses a large-scale survey of the US non-institutionalized civilian population, with a stratified, multistage probability sampling design. Details are available from this dataset, but nationally, ED charges are now more than $2,500 per visit, with payments more than $1,000.^3,4

So what’s the financial impact on the hospital of the constipated emergency department?

Start with some simple assumptions based on one of the emergency departments from the second row—the average department. The ED patient generates revenue of $1,000 for the hospital and $110 for the emergency physician, plus revenue above direct costs of $6,000 per average patient admitted to the hospital. That means the average emergency department seeing about 44,000 patients a year and admitting 16 percent of them generates $44.1 million annually in direct ED revenue, plus serves as the front door for admitted patients, who generate $43 million annually above the direct cost. That totals ED patient revenue of $238,356 per day.

Now consider the constipated emergency department. The boarding issue is influencing the care of every one of the 192 patients a day who present to this department. Each of the 40 patients admitted on an average day (typically worse on Mondays) has four extra ED hours. That results in the average ED stay for admitted patients of almost 10 hours, where nurses and techs have to provide services equivalent to those at an inpatient unit. It means the ED bed that’s occupied isn’t available for other ED patients, who are constantly arriving. This means that all ED patients receive care for at least two hours longer than at an average emergency department, with a significantly higher number of patients simply walking away.

Because of this, the emergency department loses at least seven more patients a day than the average emergency department, or 2,555 patients a year. At that pace, the direct ED revenue is $2.5 million less than it could be just from patients known to be leaving before treatment completion. At an average admission rate, about 537 of those patients would have been admitted—even more if extended boarding times force the emergency department to go on ambulance diversion. The lost admissions would have contributed another $3.2 million to the constipated hospital’s average direct revenue.

The bottom line is that total revenue loss for the constipated hospital is about $15,500 a day compared to the average emergency department. The loss of that many patients and that much revenue should force C-suite leaders to sit down with the inpatient units to find solutions for the rapid transportation of 40 patients a day to the inpatient units. Efficient hospital patient processing could expand that number to 44 patients a day.

Emergency departments that work to reduce patient boarding to less than the national average of 109 minutes show even greater benefits. Reducing ED boarding time from 147 minutes to about 92 minutes reduces walkaway rates from an average of 3.2 percent to 2.1 percent. Decreasing walkaway rates by two patients a day and increasing admissions by one more patient every three days will have a financial impact over the year of $1.5 million, or a little more than $4,000 a day.

Financial benefits extend beyond these examples. The above analyses don’t factor in the cost of improved ED staff retention, improved ED patient care experience, and improved compliance with inpatient protocols, all of which reduce inpatient costs.

There are substantial impacts of boarding on the financial performance of emergency departments, beyond the cost of stress to patients, their families, the emergency physician, and ED nurses and support staff. It’s critical for hospital leaders to improve the flow of admitted patients.

References

1. Augustine JJ. Reducing boarding time in the emergency department can improve patient care. ACEP Now. 2015;34(12);9.
2. Owens P, Elixhauser A. Hospital Admissions That Began in the Emergency Department, 2003. Statistical Brief #1. Rockville, Md.: Agency for Healthcare Research and Quality; February 2006.
3. Medicare Expenditure Panel Survey. Agency for Healthcare Research and Quality website. Accessed June 9, 2016.
4. MEPS HC-160E: 2013 Emergency Room Visits File. Agency for Healthcare Research and Quality website. Accessed June 9, 2016.