Despite the work of many emergency physicians to preserve flow for all patients, the boarding times in 2021 jumped to 169 minutes, from 121 minutes in 2020. This time interval is very cohort-dependent, ranging from 130 minutes in the smallest volume EDs, to 268 minutes in EDs that see over 80,000 patients. The time from “Door to Decision” actually decreased from 194 minutes in 2020 to 183 minutes in 2021, despite increased use of diagnostic testing due to COVID. Boarding time is more and more a problem of the hospital, not the emergency department.

However, patients who require inpatient boarding are a significant challenge to ED operations. About 68 percent of hospital admissions are processed through the ED, so this “front door” function is very important to the hospital. Continuing to trend higher, about 19 percent of ED visits result in hospital admission.

All ED patient processing times increased significantly in EDs, related to the lengthy ED boarding times. This likely increased ED walkaway rates. The overall length of stay for all ED patients increased to 195 minutes in 2021, up from 182 minutes in 2018, 184 minutes in 2019, and 186 minutes in 2020. The percentage of patients who leave the ED prior to the completion of treatment increased to 4.1 percent, from 2.8 percent in 2020, and 2.7 percent in 2019. The cohort ranges are from about 1.9 percent to 5.1 percent.

Diagnostic testing in the ED evolved with the pandemic changes. There was a 33 percent increased use of CT scans across all groups of EDs. CT scans in 2021 increased to a rate of about 32 procedures per 100 patients versus 24 procedures per 100 patients in 2019.

The Challenges to Emergency Physicians Are Significant

Emergency physicians are seeing higher acuity patients, with more complex medical needs, and an even more important role as the “front door” to the hospital. Most communities are aware of the ED as the portal for critical patients and unexpected events, and with pandemic operations the value of the ED in public health and managing community surges has become even more visible.

Emergency physician leaders must work in earnest with hospital leaders to improve the flow of inpatients in 2023 and beyond. With the lessons and data of 2021 in mind, the need to move admitted patients up to the inpatient units is an obvious management priority.