Patients overwhelmingly prefer inpatient boarding to emergency department boarding.

BACKGROUND: Boarding of admitted patients in the emergency department (ED) is a major cause of crowding. One alternative to boarding in the ED, a full-capacity protocol where boarded patients are redeployed to inpatient units, can reduce crowding and improve overall flow. OBJECTIVE: Our aim was to compare patient satisfaction with boarding in the ED vs. inpatient hallways. METHODS: We performed a structured telephone survey regarding patient experiences and preferences for boarding among admitted ED patients who experienced boarding in the ED hallway and then were subsequently transferred to inpatient hallways. Demographic and clinical characteristics, as well as patient preferences, including items related to patient comfort and safety using a 5-point scale, were recorded and descriptive statistics were used to summarize the data. RESULTS: Of 110 patients contacted, 105 consented to participate. Mean age was 57 ± 16 years and 52% were female. All patients were initially boarded in the ED in a hallway before their transfer to an inpatient hallway bed. The overall preferred location after admission was the inpatient hallway in 85% (95% confidence interval 75-90) of respondents. In comparing ED vs. inpatient hallway boarding, the following percentages of respondents preferred inpatient boarding with regard to the following 8 items: rest, 85%; safety, 83%; confidentiality, 82%; treatment, 78%; comfort, 79%; quiet, 84%; staff availability, 84%; and privacy, 84%. For no item was there a preference for boarding in the ED. CONCLUSIONS: Patients overwhelmingly preferred the inpatient hallway rather than the ED hallway when admitted to the hospital.

The association between transfer of emergency department boarders to inpatient hallways and mortality: a 4-year experience.

STUDY OBJECTIVE: We developed and implemented an institutional protocol aimed at reducing crowding by admitting boarded patients to hospital inpatient hallways. We hypothesized that transfer of admitted patients from the emergency department (ED) to inpatient hallways would be feasible and not create patient harm. METHODS: This was a retrospective cohort study in a suburban, academic ED with an annual census of 70,000. We studied consecutive patients admitted from our ED between January 2004 and January 2008. In 2001, a multidisciplinary team developed and implemented an institutional protocol in which admitted adult patients boarded in the ED were transferred to hospital inpatient hallways under select conditions. We extracted data from the electronic medical record system, measuring patient demographics, ED disposition (discharge, admit to floor, admit to hallway), ED length of stay, and inhospital mortality. We report ED length of stay, subsequent transfer to an ICU, and hospital mortality of patients admitted to standard and hallway inpatient beds. RESULTS: Of 55,062 ED patients admitted, there were 1,798 deaths. Of all admissions, 2,042 (4%) went to a hallway; 53,020 went to a standard bed. Patients admitted to standard and hallway beds were similar in age (median [interquartile range] 55 years [37 to 72 years] and 54 years [41 to 70 years], respectively) and sex (48.2% and 50% female patients, respectively). The median (interquartile range) times from ED triage to actual admission in patients admitted to standard and hallway beds were 426 minutes (306 to 600 minutes) and 624 (439 to 895 minutes) minutes, respectively (P<.001). Median ED census at triage was lower for standard bed admissions than for hallway patients (44 [33 to 53] versus 50 [38 to 61], respectively, P<.001). Inhospital mortality rates were higher among patients admitted to standard beds (2.6%; 95% confidence interval [CI] 2.5% to 2.7%) than among patients admitted to hallway beds (1.1%; 95% CI 0.7% to 1.7%). ICU transfers were also higher in the standard bed admissions (6.7% [95% CI 6.5% to 6.9%] versus 2.5% [95% CI 1.9% to 3.3%]). CONCLUSION: Transfer of ED-boarded admitted patients to an inpatient hallway occurs during high ED census and waiting times for admission but does not appears to result in patient harm.

Emergency department activation of an interventional cardiology team reduces door-to-balloon times in ST-segment-elevation myocardial infarction.

STUDY OBJECTIVE: American Heart Association/American College of Cardiology guidelines recommend door-to-balloon times of fewer than 90 minutes in patients with acute ST-segment-elevation myocardial infarction. We hypothesized that immediate activation of an interventional cardiology team (code H) would reduce the time to percutaneous coronary intervention by 1 hour and increase the proportion of patients undergoing percutaneous coronary intervention within 90 minutes of arrival. METHODS: Study design was a before-and-after trial in an academic suburban emergency department (ED) with a certified cardiac catheterization laboratory. Subjects were a consecutive sample of patients presenting to the ED with ST-segment-elevation myocardial infarction evident on the initial ECG. Patients without chest pain and refusing catheterization were excluded. The intervention was the use of a central paging system for activation of the interventional cardiology team (attending physician, fellow, nurse, technician) by emergency physicians in patients presenting to the ED with ST-segment-elevation myocardial infarction. Measures were demographic and clinical information collected with standardized data collection forms. Outcomes were door-to-balloon times and the proportion of patients undergoing percutaneous coronary intervention within 90 minutes of arrival. Groups were compared with chi2 and t tests. RESULTS: There were 97 patients included in the study; 43 were treated in the 2 years before implementation of the code H and 54 patients were treated the subsequent 2 years. Mean age (SD) was 56.9 years (13.7), 27% were women, and 86% were white. Groups were similar in age, sex, and race. Implementation of a code H reduced the median door-to-balloon time by 68 minutes (from 176 to 108 minutes; P<.001) and increased the proportion of patients undergoing percutaneous coronary intervention within 90 minutes from 2.8% to 29.0% (mean difference 26.5; 95% confidence interval 15.0 to 36.9). To determine whether further improvements occurred, 48 patients treated in 2006 showed a 20-minute further reduction in door-to-balloon time; 52% underwent angioplasty within 90 minutes of ED presentation. CONCLUSION: Institutional implementation of a protocol that requires emergency physicians to activate an interventional cardiology team response in ED patients with ST-segment-elevation myocardial infarction reduces the door-to-balloon time and increases the proportion of patients undergoing percutaneous coronary intervention within 90 minutes.