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

ABSTRACT

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