The Waiting Game: Emergency Department Boarding and Its Financial Costs for Patients, Hospitals, and Clinicians

Background: Emergency departments (EDs) have experienced increased patient boarding even before the pandemic which has led to significant challenges for both patients and clinicians. The COVID pandemic has only exacerbated ED crowding despite reduced ED volumes nationally. ED boarding has been erroneously attributed to inefficient ED practices but is often largely the result of hospital and systemic inefficiencies. While ED boarding is not solely an ED problem, the financial impact of boarding on the ED can be significant and the cost of ED crowding is often largely borne by already overburdened EDs. Study Objectives: There were two primary objectives;1) To quantify the number of ED beds occupied by inpatient boarding patients, 2) To estimate the financial impact of boarding on the ED in a large, academic, safety-net hospital. Method(s): A retrospective, cohort review of all ED encounters from July 1, 2020, through June 30, 2021, were identified at our large, academic, safety-net trauma center. Performance metrics were retrieved from a novel, interactive, digital data dashboard at the Zuckerberg San Francisco General Hospital (ZSFGH) including average Length of Stay (LOS) and Total Boarding Minutes. Boarding was defined as time spent occupying an ED bed beyond 120 minutes after the admit disposition was determined as defined by the Agency for Healthcare Research and Quality (AHRQ). An estimate of total missed encounters due to ED boarding time was made and total potential charges and revenue were then estimated using an institutional average of estimated charges as well as average realized reimbursement rate. Result(s): There were a total of 54,612 encounters, of which 50,980 (93.3%) were included and 3,632 (6.7%) were excluded due to alternative dispositions, such as Absent Without Leave (AWOL), Left Without Being Seen (LWBS), Left Without Being Triaged (LWBT) and Nursing Referrals (RN Referrals). Included were 11,850 (23.2%) admissions and 39,130 (76.8%) discharges and transfers. Total annual boarders were 7,410 (62.5%) with a total of 3,782,670 boarding minutes. The mean LOS for our ED patients during this period was 395 minutes (753 for admissions and 288 for discharges and transfers) resulting in an estimate of potential missed encounters of 9,576. The institutional average charge for all-comers to the ED is $780. At 9,576 missed encounters, an estimate for potential lost charges was $7.47M and at an average reimbursement rate of 23%, potential revenue loss of $1.72M [Figure 1]. During the pre-pandemic period with available data (August 1, 2019 - February 29, 2020) when boarding and nurse staffing were not as limited, the daily census was 184.1 patients, excluding LWBS, LWBT, and RN Referrals. During the pandemic period with significant ED boarding and nursing staffing shortages, the daily census was 149.6. Including the potential daily missed encounters of 26.2 would result in a total potential daily census of 175.8. Thus, we assume there would be sufficient patient volume and demand to occupy all available ED beds if boarding were eliminated. Conclusion(s): ED boarding is due to systemic health care system failures but results in significant lost ED revenue further straining already over-burdened EDs. Improving hospital patient flow can improve ED patient flow and revenues both during and after the COVID pandemic. [Formula presented] Yes, authors have interests to disclose Disclosure: FujiFilm-SonoSite Consultant/Advisor FujiFilm-SonoSite Disclosure: Inflammatix Consultant/Advisor Inflammatix Copyright © 2022

Emergency Department Nursing Staffing Has Significant Financial Consequences for Patients, Hospitals, and Clinicians

Background: Emergency departments (EDs) have experienced increases in patient boarding, which has resulted in significant challenges to providing quality care. The COVID pandemic has exacerbated ED crowding despite reduced ED volumes nationally, which is in part due to national ED nursing shortages. Nursing-specific operational inefficiencies can have detrimental financial consequences for the ED and hospitals. Study Objectives: There were two primary objectives: 1) To quantify the amount of ED beds unavailable due to nurse-staffing challenges 2) To estimate the financial impact of this reduced capacity on the ED. Method(s): A retrospective, cohort review of all ED encounters from January 1, 2021 - December 31, 2021, was identified at our large, academic, safety-net trauma center. Performance metrics were retrieved from a novel, interactive, digital data dashboard at the Zuckerberg San Francisco General Hospital (ZSFGH). Average daily staffed nursing beds were obtained during two key time points daily: 11am and 7pm from Q4- 2021 (October 1, 2021 - December 31, 2021) and extrapolated for the calendar year. Total unavailable ED bed minutes were determined based on nursing staffing as were total potential missed encounters due to unavailable ED beds. These were estimated using the average LOS for ED encounters. Average institutional ED charges and realized payments were then used to determine a financial estimate of the impact of the nursing shortage during Q4-2021 and annualized for 2021. We assume, based on pre-pandemic census data, that there is sufficient ED demand and volume to occupy all available ED beds. Result(s): The ZSFGH is a 59-bed ED that when maximally staffed has a weighted average of 56.25 beds daily, accounting for nighttime closures. During the review period, the average daily nursing-staffed beds during Q4-2021 were 47.7 (84.7%). From January 1, 2021 - December 31, 2021, there were 57,888 encounters of which 53,012 (91.6%) were included and 4,876 (8.4%) were excluded due to alternative dispositions such as Absent Without Leave (AWOL), Left Without Being Seen (LWBS), Left Without Being Triaged (LWBT) and Nursing Referrals (RN Referrals). The total unstaffed ED bed minutes was an estimated 4,511,400. The average LOS excluding AWOL, LWBS, LWBT, RN Referrals, and Against Medical Advice (AMA) during this time period was 411 minutes resulting in an estimated 10,977 potential missed encounters, an estimated $8.56M in lost potential charges, and $1.97M in potential lost revenue [Figure 1]. During the pre-pandemic period with available data (August 1, 2019 - February 29, 2020) when boarding and nursing staffing weren't as limited, the daily census was 184.1 patients, excluding LWBS, LWBT, and RN Referrals with an average LOS of 407 minutes for a total daily bedtime of 74,929 minutes for a utilization of 92.5%. During this period, the total daily census with LWBS, LWBT, and RN Referrals was 210.1 patients. These additional patients would account for another 10,582 bed minutes for a total bed utilization of 85,511 mins (105.6%). Conclusion(s): The COVID pandemic has resulted in increasing challenges for already strained EDs. Increasing national nursing shortages reduce operational performance and result in a significant financial loss to EDs. Greater attention to the financial consequences of nursing shortages on EDs may allow for improved resource allocation, capacity recovery, and financial performance. [Formula presented] Yes, authors have interests to disclose Disclosure: FujiFilm-SonoSite Consultant/Advisor FujiFilm-SonoSite Disclosure: Inflammatix Consultant/Advisor Inflammatix Copyright © 2022

Improving Access to Clinical Guidelines: Focus on the End User

Study Objectives: Clinical guidelines are frequently used in the emergency department (ED) to standardize patient care, support clinical decision-making, and ensure quality and safety. While the clinical content of such guidelines is developed and maintained by expert clinicians in collaboration with departments across the health system, key principles of effective graphic design and presentation are not uniformly applied. In our ED, these siloed approaches to guideline design have led to a wide range of formats, from text-based to visual flow charts, that are accessed less than 10 times a month. In interviews with ED clinicians at our institution, we discovered clinical guideline presentation and readability were directly related to ease and rate of use. Therefore, we aimed to create and implement standardized best practices, developed with the end user in mind, to increase the usage of clinical guidelines for patient care in our ED. Methods: We assembled a team of designers, frontline clinicians, and leadership to iteratively develop a standardized process for converting ED clinical guidelines to a new, end user-centered format. In this process, we focused on key principles of design including spatial positioning, color, and flow. We developed two templates: a multi- step protocol template with branch points, and a single-step protocol template. Several key qualities arose during our design process: 1) Visualizing information on a single page;2) Eliminating and condensing text where possible;3) Utilizing left to right horizontal flow;4) Standardizing use of color to indicate acuity and urgency of each step. Templates were developed in Google Slides for ease of adaptation, and a rigorous change-control process was formalized to ensure that redesigned guidelines retained clinical integrity. The guidelines were organized into categories: Medical, Trauma, Pediatrics, Geriatrics and Logistics and then uploaded to an open access, mobile-friendly platform, E*Drive (https://edrive.ucsf.edu). Results: Since the launch of E*Drive, we have redesigned over 50 clinical guidelines. User data indicates that standardized guidelines are increasingly accessed compared to prior unstandardized versions, which were accessed a total of 25 times from June 2020 to September 2020. Our redesigned digital platform, which houses the clinical guidelines along with other clinical resources, now averages 343 unique users per month. Usage has grown by 375% since E*Drive site launch in October 2020 (Figure 1). The templated format and clearly-defined best practices have enabled our team to have a <24-hour turnaround time for the creation of new clinical guidelines, which is particularly important for rapidly changing COVID-19 pandemic-related information, including real-time census sharing guidelines. Conclusion: Creating usable clinical guidelines in the ED is particularly challenging given collaboration with siloed departments with varying guideline structure and design. A formal design and change-control process for standardizing clinical guidelines has increased clinicians access to guidelines while retaining clinical integrity of guidelines in our ED. [Formula presented]

Managing Burnout in a Prolonged Crisis: A 2-Wave Cross-Sectional Analysis of Emergency Department Personnel Over 6 Months of the COVID-19 Pandemic

Study Objective: Management research suggests that inclusive leaders, problem-solving teams and clear processes might matter for addressing uncertainty, but how these factors unfold during prolonged crisis and their relationship to burnout is not well understood. The study objective was to examine associations between teamwork and leadership factors and clinician burnout as the care burden increased over 8 months of the COVID-19 pandemic. Methods: Across two California hospitals, cross-sectional surveys were administered to emergency department (ED) personnel in July and December 2020 (N1 = 328 & N2 = 356). Overall burnout (“Overall, based on your definition of burnout, how would you rate your level of burnout?”) and worsening burnout during the crisis (“Compared to your level of burnout prior to COVID, to what extent is your current level of burnout worse, improved or the same?”) were measured on a 5-point Likert scale and analyzed as binary variables. Burnout was defined as having at least some burnout (ie, reporting at least “definitely” burning out). Worsening burnout was defined as either burnout that had “gotten much worse” or “gotten a little worse” since before the COVID-19 crisis. These outcomes were assessed in relation to joint problem-solving (JPS), clear process and leader inclusiveness using logistic regressions. Models controlled for age, sex, race, location, tenure and shift, as well as county COVID-19 case burden using open-access data from John Hopkins University’s Coronavirus Resource Center. Results: The sample across both waves consisted of 75 attendings (14.79%), 50 residents/fellows (9.89%), 38 advance practice providers (5.56%), 254 registered nurses (37.13%) and 90 other ED personnel (therapists, social workers, etc.) (13.16%). Burnout increased over time, where 32.22% reported burnout in wave 1 and 56.51% in wave 2. Worsening burnout also increased over time, 57.32% to 80.52% respectively. Clear process and leader inclusiveness were significantly associated with lower odds of burnout across both time points, 0.28 (p < 0.001) and 0.45 (p < 0.05) in wave 1 and 0.30 (p <0.01) and 0.35 (p < 0.01) in wave 2, respectively (Figure 1). Joint-problem solving was significantly associated with lower odds of burnout in wave 2 only, 0.60 (p-value < 0.01). All factors were significantly associated with lower odds of worsening burnout in wave 2 only, 0.45 (p < 0.01) for JPS, 0.29 (p < 0.01) for clear process and 0.37 (p < 0.05) for leader inclusiveness (Figure 1). Conclusions: During a prolonged crisis, communicating a clear process to ED personnel, and encouraging leaders to include staff in decisions may do more to reduce burnout early on. However, solving problems together and relying on staff interchangeably may continue to prevent burnout as time goes on and the burden of disease increases. When managing burnout among ED personnel, leaders should focus initially on providing structure, and then, reinforce strong teamwork to help their staff continue on. [Formula presented]