COMMENTARY
Policy Roundtable: Emergency Department Boarding and Hospital Quality
I
n this issue of Academic Emergency Medicine, Pitts and colleagues1 present findings from a national study of emergency department (ED) inpatient boarding. Their findings represent one of the first examinations of hospital ED boarding across the United States. In this study, the authors describe the extent, regional variations and hospital- and visit-level characteristics that are associated with inpatient boarding. These findings coincide with continued national and local interest in efforts to measure, report, and reduce the practice of inpatient boarding in the ED. Academic Emergency Medicine convened a team of national leaders in policy and research related to boarding, quality measurement, hospital payment, and emergency care health policy to discuss this topic. The roundtable discussion, including the lead author of the study, starts with the study’s findings and moves into a broader discussion about inpatient boarding in the ED and its effect on quality of hospital care in the United States. Key parts of the discussion are published here (see supporting information). Roundtable Participants: Zachary Meisel (moderator, University of Pennsylvania), Steven Pitts (study author, Emory University), Jesse Pines (George Washington University), Kate Goodrich (Centers for Medicare and Medicaid Services), and Brendan Carr (Emergency Care Coordination Center, Office of the Assistant Secretary of Preparedness and Response, HHS). ************************* WHAT WAS THE IMPETUS FOR THIS STUDY? Pitts: I’ve been in practice for many years including at a big municipal charity teaching hospital. A few years ago we had a disastrous problem where practically every ED bed was occupied by an inpatient waiting for a hospital bed. The question was: how common was this? Then I went and spent a year at the National Center for Health Statistics (NCHS). The survey added a boarding question
Author contributions: ZFM conceived of the commentary. All other authors participated equally. The authors have no relevant financial information or potential conflicts of interest to disclose. A related article appears on page 497.
570
ISSN 1069-6563 PII ISSN 1069-6563583
to the National Hospital Ambulatory Medical Care Survey (NHAMCS) data in 2009 and 2010 about whether or not a given hospital boards inpatients and whether it boards patients more than 2 hours. The survey also tallied the number of minutes spent boarding in the ED. This study analyzes those new survey items. One concern was that there was a fairly high nonresponse rate (as high as 25% of admissions)—so we accounted through a variety of adjustments. But after our adjustments, it didn’t make a huge difference in the median boarding time—which was around 75 minutes. So we went ahead with the analysis. The real bottom line is in Table 3 of the manuscript. We aggregated data and we found that: 1. The lower two quartiles of boarding duration were in relatively small ERs. 2. The higher two quartiles were in big ERs. It meant there were two boarding tiers of ERs (by volume). Also, things that you might intuitively think would impact boarding rates (at the visit level) such as poverty didn’t have much of an impact on boarding. We did a separate analysis on the ED-level data—and then it turned out that certain things were associated with boarding levels, namely, urban hospital, Northeast hospitals, and hospitals that take care of larger proportions of non-Hispanic black patients. But these could be confounded by ED size, which could not be incorporated into the multivariable model. Those were the main highlights of what we found. HOW DO THESE FINDINGS FIT INTO WHAT IS ALREADY KNOWN ABOUT BOARDING AND ED CROWDING? Pines: The earliest reports of crowding occurred back in the late ‘80s and early ‘90s. Since that time, there has been a lot of research looking at the relationship between crowding and quality of care and outcomes. There are two concepts: the crowdedness that an individual ED faces and the length of stay that the patient sees—and a piece of this is the boarding time. There is robust literature that shows that crowding is associated with important delays in care, less patient-centered care, lower rates of pain control for patients in severe pain, and also higher complication rates. It has been harder to show that crowding is linked to mortality. We think there is lots of trouble pinpointing the time that
© 2014 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12381
ACADEMIC EMERGENCY MEDICINE • May 2014, Vol. 21, No. 5 • www.aemj.org
the admission decision is made, which varies between hospitals: when the bed request is made versus the time the physician makes the decision to admit. So boarding time has been a moving target and this is reflected in Steve’s study. THERE WERE SOME NEW FINDINGS LIKE CONNECTING THINGS LIKE VOLUME TO BOARDING AND THE LACK OF AN ASSOCIATION BETWEEN PAYER STATUS FOR EACH VISIT AND BOARDING. DOES THIS STUDY CHANGE ANYTHING? Pines: So there have been a few studies that bigger EDs are associated with a few performance measures and I think that reflects the complexity of larger institutions and the greater variation in daily crowding in the ED. It is more difficult to keep boarding times low in a big hospital. Imagine a 10-bed rural ED versus an inner-city safety net hospital—the complexity of managing the admission decision is very different in those two hospitals. For example, the number of different potential locations within a hospital that the patient could go to tends to be greater at the bigger EDs. We’ve found when you have a lot of complexity at the big hospitals, it leads to boarding. For example, if you just have one internal medicine service and one internal medicine floor, it is a very different prospect than having a number of subspecialty floors. What happens is that the more you break the admissions services into separate units, that creates additional choke points in the hospital. This is what we are seeing in Dr. Pitts’ study. The broader question from a quality measurement perspective is that if we are going to retain these quality measures of crowding, how are we going to account for the fact that bigger hospitals run differently than small hospitals? HOW DO THE CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) THINK ABOUT BOARDING? Goodrich: Let me start by talking about how we select measures for our program and in particular how we select measures for payment programs, because they may not always be the same. The boarding measures are a subset of a much larger portfolio of measures for the inpatient quality reporting program and the hospital value-based purchasing program. We have really started to rebalance our portfolio of measures from ones that are very process measure heavy to focusing much more on outcome based measures— including emphasizing care coordination and the patient experience. In other words, quality measures that really matter to patients. I would say that the ED boarding measures, while they have been classified in this paper as outcome measures (and they are an outcome, but not necessarily a clinical outcome), actually touch on multiple domains of measurement that are high priorities for us at CMS. The first would of course be a focus on clinical care. But they also touch very strongly on patient experience (although they are
571
not considered directly patient experience measures, but if you are a patient and you are boarding in the ED for a long time that will undoubtedly affect your experience in the hospital). Boarding touches on care coordination and communication and ultimately may touch on cost. When we are selecting measures for CMS programs, we think about three main things when we are building a case for why we want to use a particular measure. First, is there a performance gap? Is there an actual quality problem in a particular area? Second, is there variation? For example, if everyone is performing really well with, say, giving aspirin for patients with acute myocardial infarction, then it becomes less important for our program and over time you might see those measures being withdrawn. Last, is this measure important to patients? And I think with the boarding measure (and its associated measures), it meets those three criteria. Now I also will say that once we implement a program, we follow over time the impact of that measure (including its unintended consequences, because we may not always know at the time of implementation what its effects will be). We follow the literature and we do our own internal analyses. So I would say that this article was very interesting for me to read and contributes to our understanding of what correlates with performance. Recently, I was working as a hospitalist in a busy urban east coast hospital and I can say that these findings are not surprising. However, the paper doesn’t necessarily answer all the questions that we may have about correlations with boarding time. It starts to ask some of the additional questions that we would like to see answered as we are continuing to implement these measures. Studies like this could make us think about what we do with this measure: for example, if we use it just in a public reporting sense or tie it to payment. But at the end of the day, we still think of boarding as an important measure. THIS PAPER CAME OUT OF A GROUP OF RESEARCHERS WHO WERE AFFILIATED WITH THE EMERGENCY CARE COORDINATION CENTER (ECCC). SO HOW DOES THIS STUDY FIT INTO THE MISSION OF THAT PROGRAM? Carr: Thanks, Dr. Meisel, for putting together this dialogue. This paper touches on our priorities in a number of ways. For those who don’t know, the ECCC is located in the office of the Assistant Secretary for Preparedness and Response (ASPR) at the U.S. Department of Health and Human Services (HHS). ECCC’s focus is on day-to-day emergency care, and we often approach this from the perspective of how day-to-day emergency care is tied to preparedness and our ability to respond. The Assistant Secretary, Dr. Lurie, is fond of saying that we recognize that true preparedness requires an emergency care system and health care system that is highly functional and high quality every day. There are four key components to our mission: 1) lead the way into a patient- and community-centered emergency care system, 2) make sure that the system we build is integrated
572
into the larger system (we don’t think that emergency care should be a carve-out), 3) build a system of emergency care that is high quality, and 4) make sure that the emergency care system we are building makes us more prepared and ready to respond in a time of local or national need. I think this paper touches on all of these. It is very easy for me to see that boarding is a patient-centered outcome. It is also very easy for me to see that there is a community tie—our goal shouldn’t just be to determine if our hospitals are crowded, but if ALL of our hospitals in a community are crowded. This paper starts to shine a flashlight a bit on the geography issues here: it suggests that the Northeast has more of a problem with boarding than other regions of the country. A few people on the call deserve kudos for long-standing work changing the way that crowding and boarding is seen— pushing the world to understand that crowding is a hospital problem, not an ED problem. At the end of the day, it doesn’t matter if it is my family member or my neighbor lying in the hallway for hours—either way, we can do better. I would also argue that we should think about boarding from a preparedness perspective. And I would point interested parties toward a National Quality Forum (NQF) report a few years ago that created the tie between boarding and regional preparedness. When we look at this paper, we see that high-volume hospitals in the Northwest have the worst boarding problems. They are also at risk for natural disasters like flooding as we saw in Hurricane Sandy and man-made disasters like the Boston bombing. Their tremendous day-to-day crowding could present a real challenge when they need to surge to meet the demand for services created by disasters. ARE THERE SOLUTIONS TO BOARDING AT SPECIFIC HOSPITALS? Pines: There are local solutions that can effectively improve the boarding measure within individual hospitals. These issues are sometimes due to capacity—particularly in critical care units. But what goes into smoothing the transition to inpatient beds has less to do with capacity and the administrative work and culture within hospitals that allows patients to sit in the ED for a long time. Often the incentives are all misaligned. Boarding is worse in places that are an “us vs. them” culture—where units don’t work together to solve hospital-wide problems. I think a lot of this is addressable at a local level. There is a performance gap and Steve’s study reinforces that. There is variation across the country. Carr: I do think that a piece of this problem is that “we” the emergency care community, “we” the primary care community, and “we” the health system administration—don’t really know what “we” want the emergency department to be. So I get Jesse’s point that the system issues might be addressable but it makes me wonder to what extent the system believes that it is important to fill a bed with an ED patient. I am often frustrated by ongoing language around “inappropriate” use of the ED and whether people
Meisel et al. • ED BOARDING & HOSPITAL QUALITY
ought to be there and whether people should be going through the ED to get to the hospital. This dialogue is difficult because it points to the three different systems that are being built. The first is a backup to the primary care system—it’s a place to see patients with exacerbations of chronic illnesses that diagnoses them, treats them, and sends them home with a plan to go back to their usual source of care. The second is a conduit to the inpatient setting hospital. Fifty percent of admissions [note: 80% of unscheduled admissions] come through the ED these days and many outpatient providers without inpatient privileges refer patients in to be evaluated because they think they may end up requiring admissions. And the last is the caricature of the ED that we see on TV—the focus on life and limb threats. We need to better articulate how we want acute care in the U.S. to be managed— because if we can do that, the systems can fix themselves. We will no longer see management that is efficiently building one of these three systems while patients and providers are hoping for a different end result. We need to set a goal that we can race toward. CMS has said that they want to align incentives in a clear way so that people can innovate to get over the finish line. ISN’T THIS OBVIOUS THAT THIS IS A PROBLEM WHEN WE CAN’T TAKE CARE OF PATIENTS WITH LIFE AND LIMB THREATS WHEN THE ED IS CLOGGED WITH INPATIENTS? Pines: As we move to models that emphasize value over volume, it might lead to patients spending more time in the ED because it may be more efficient, for example, to get an MRI for a neurology patient in the ED and discharge after it is negative than to admit them for 2 to 3 days. Carr: I think he is right that we are going to see longer ED visits because we are doing inpatient workups in the ED. People are not talking about this in the right frame yet. In other words, you can go to the ED to get in 8 hours what used to be a three-day admission. People are still talking about going to the ED as the “wrong” place compared to your usual place of care. But it’s being used for something different and we haven’t built capacity for that. TO WHAT EXTENT THIS CONCEPT OF LARGEVERSUS SMALL-VOLUME HOSPITALS AND ITS RELATIONSHIP WITH BOARDING IMPACT THE WAY CMS THINKS ABOUT THIS PROBLEM? Goodrich: One of the things that I’ve been thinking since I read this paper and during this conversation is that maybe we need to look at large- compared to small-volume hospitals. When we see poor performers move into medium- or high-performing ranges that is good. So what would be interesting is to understand if there is variation within the high-volume hospitals or if everyone with high volume has long ED boarding times. In other words, is this just such a huge problem in all high-volume hospitals that there may not be an opportunity for improvement?
ACADEMIC EMERGENCY MEDICINE • May 2014, Vol. 21, No. 5 • www.aemj.org
So for me that would be one of the next questions that would be interesting to answer. I don’t think that what we’ve been talking about here and what Steve Pitts found in his study would necessarily lead CMS to remove the boarding measure. We still think it is a critically important concept. But it certainly piques our interest in following the literature to see how we could improve upon the measure because I think this is such an important patient-centered construct. As Brendan said, we want to get to the right outcome, we don’t really care how hospitals go about doing it as long as patient care isn’t compromised. We think this is an important outcome in particular for patients. So we will follow where the literature takes us in learning more about this important measure. SO CAN WE FIND THE POSITIVE DEVIANTS AND OUTLIERS SO WE CAN LOOK AT THIS PROBLEM WITHIN CATEGORY OF HOSPITAL? Carr: It is really interesting to me to think about how to build a system of incentives and maybe measures that allow people to innovate not just within their facility— but within their community. From my perspective, when a giant hospital goes down in NYC, if every other hospital is terribly crowded, it really is important to think about how we might safely find a place for those patients to safely go. So if our goal is only to talk at the hospital level about the ability to move patients rapidly into their inpatient units, is that enough? I don’t know. If I am a member of a community, I want more. I would want hospitals that compete every day for their referral care, to cooperate when it comes time to manage a surge. This is what patient- and community-centered care is. Zachary F. Meisel, MD, MPH, MSc ([email protected]) Center for Emergency Care Policy Research Department of Emergency Medicine Perelman School of Medicine Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia, PA Stephen R. Pitts, MD, MPH Department of Emergency Medicine Emory University Atlanta, GA
573
Jesse M. Pines, MD, MBA, MSCE Emergency Medicine and Health Policy George Washington University School of Medicine and Health Sciences Washington, DC Kate Goodrich, MD, MHS Centers for Medicare and Medicaid Services Baltimore, MD Department of Medicine George Washington University School of Medicine and Health Sciences Washington, DC Brendan G. Carr, MD, MA, MSc Center for Emergency Care Policy Research Department of Emergency Medicine Perelman School of Medicine Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia, PA Emergency Care Coordination Center Office of the Assistant Secretary for Preparedness and Response U.S. Department of Health and Human Services Washington, DC
Supervising Editor: David C. Cone, MD.
Reference 1. Pitts S, Vaughn FL, Gautreau MA, Cogdell MW. A cross-sectional study of emergency department boarding practices in the United States. Acad Emerg Med 2014;21:497–503. Supporting Information The following supporting information is available in the online version of this paper: Data Supplement S1. Audio file of roundtable discussion.
Policy Roundtable: Emergency Department Boarding and Hospital Quality
I
n this issue of Academic Emergency Medicine, Pitts and colleagues1 present findings from a national study of emergency department (ED) inpatient boarding. Their findings represent one of the first examinations of hospital ED boarding across the United States. In this study, the authors describe the extent, regional variations and hospital- and visit-level characteristics that are associated with inpatient boarding. These findings coincide with continued national and local interest in efforts to measure, report, and reduce the practice of inpatient boarding in the ED. Academic Emergency Medicine convened a team of national leaders in policy and research related to boarding, quality measurement, hospital payment, and emergency care health policy to discuss this topic. The roundtable discussion, including the lead author of the study, starts with the study’s findings and moves into a broader discussion about inpatient boarding in the ED and its effect on quality of hospital care in the United States. Key parts of the discussion are published here (see supporting information). Roundtable Participants: Zachary Meisel (moderator, University of Pennsylvania), Steven Pitts (study author, Emory University), Jesse Pines (George Washington University), Kate Goodrich (Centers for Medicare and Medicaid Services), and Brendan Carr (Emergency Care Coordination Center, Office of the Assistant Secretary of Preparedness and Response, HHS). ************************* WHAT WAS THE IMPETUS FOR THIS STUDY? Pitts: I’ve been in practice for many years including at a big municipal charity teaching hospital. A few years ago we had a disastrous problem where practically every ED bed was occupied by an inpatient waiting for a hospital bed. The question was: how common was this? Then I went and spent a year at the National Center for Health Statistics (NCHS). The survey added a boarding question
Author contributions: ZFM conceived of the commentary. All other authors participated equally. The authors have no relevant financial information or potential conflicts of interest to disclose. A related article appears on page 497.
570
ISSN 1069-6563 PII ISSN 1069-6563583
to the National Hospital Ambulatory Medical Care Survey (NHAMCS) data in 2009 and 2010 about whether or not a given hospital boards inpatients and whether it boards patients more than 2 hours. The survey also tallied the number of minutes spent boarding in the ED. This study analyzes those new survey items. One concern was that there was a fairly high nonresponse rate (as high as 25% of admissions)—so we accounted through a variety of adjustments. But after our adjustments, it didn’t make a huge difference in the median boarding time—which was around 75 minutes. So we went ahead with the analysis. The real bottom line is in Table 3 of the manuscript. We aggregated data and we found that: 1. The lower two quartiles of boarding duration were in relatively small ERs. 2. The higher two quartiles were in big ERs. It meant there were two boarding tiers of ERs (by volume). Also, things that you might intuitively think would impact boarding rates (at the visit level) such as poverty didn’t have much of an impact on boarding. We did a separate analysis on the ED-level data—and then it turned out that certain things were associated with boarding levels, namely, urban hospital, Northeast hospitals, and hospitals that take care of larger proportions of non-Hispanic black patients. But these could be confounded by ED size, which could not be incorporated into the multivariable model. Those were the main highlights of what we found. HOW DO THESE FINDINGS FIT INTO WHAT IS ALREADY KNOWN ABOUT BOARDING AND ED CROWDING? Pines: The earliest reports of crowding occurred back in the late ‘80s and early ‘90s. Since that time, there has been a lot of research looking at the relationship between crowding and quality of care and outcomes. There are two concepts: the crowdedness that an individual ED faces and the length of stay that the patient sees—and a piece of this is the boarding time. There is robust literature that shows that crowding is associated with important delays in care, less patient-centered care, lower rates of pain control for patients in severe pain, and also higher complication rates. It has been harder to show that crowding is linked to mortality. We think there is lots of trouble pinpointing the time that
© 2014 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12381
ACADEMIC EMERGENCY MEDICINE • May 2014, Vol. 21, No. 5 • www.aemj.org
the admission decision is made, which varies between hospitals: when the bed request is made versus the time the physician makes the decision to admit. So boarding time has been a moving target and this is reflected in Steve’s study. THERE WERE SOME NEW FINDINGS LIKE CONNECTING THINGS LIKE VOLUME TO BOARDING AND THE LACK OF AN ASSOCIATION BETWEEN PAYER STATUS FOR EACH VISIT AND BOARDING. DOES THIS STUDY CHANGE ANYTHING? Pines: So there have been a few studies that bigger EDs are associated with a few performance measures and I think that reflects the complexity of larger institutions and the greater variation in daily crowding in the ED. It is more difficult to keep boarding times low in a big hospital. Imagine a 10-bed rural ED versus an inner-city safety net hospital—the complexity of managing the admission decision is very different in those two hospitals. For example, the number of different potential locations within a hospital that the patient could go to tends to be greater at the bigger EDs. We’ve found when you have a lot of complexity at the big hospitals, it leads to boarding. For example, if you just have one internal medicine service and one internal medicine floor, it is a very different prospect than having a number of subspecialty floors. What happens is that the more you break the admissions services into separate units, that creates additional choke points in the hospital. This is what we are seeing in Dr. Pitts’ study. The broader question from a quality measurement perspective is that if we are going to retain these quality measures of crowding, how are we going to account for the fact that bigger hospitals run differently than small hospitals? HOW DO THE CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) THINK ABOUT BOARDING? Goodrich: Let me start by talking about how we select measures for our program and in particular how we select measures for payment programs, because they may not always be the same. The boarding measures are a subset of a much larger portfolio of measures for the inpatient quality reporting program and the hospital value-based purchasing program. We have really started to rebalance our portfolio of measures from ones that are very process measure heavy to focusing much more on outcome based measures— including emphasizing care coordination and the patient experience. In other words, quality measures that really matter to patients. I would say that the ED boarding measures, while they have been classified in this paper as outcome measures (and they are an outcome, but not necessarily a clinical outcome), actually touch on multiple domains of measurement that are high priorities for us at CMS. The first would of course be a focus on clinical care. But they also touch very strongly on patient experience (although they are
571
not considered directly patient experience measures, but if you are a patient and you are boarding in the ED for a long time that will undoubtedly affect your experience in the hospital). Boarding touches on care coordination and communication and ultimately may touch on cost. When we are selecting measures for CMS programs, we think about three main things when we are building a case for why we want to use a particular measure. First, is there a performance gap? Is there an actual quality problem in a particular area? Second, is there variation? For example, if everyone is performing really well with, say, giving aspirin for patients with acute myocardial infarction, then it becomes less important for our program and over time you might see those measures being withdrawn. Last, is this measure important to patients? And I think with the boarding measure (and its associated measures), it meets those three criteria. Now I also will say that once we implement a program, we follow over time the impact of that measure (including its unintended consequences, because we may not always know at the time of implementation what its effects will be). We follow the literature and we do our own internal analyses. So I would say that this article was very interesting for me to read and contributes to our understanding of what correlates with performance. Recently, I was working as a hospitalist in a busy urban east coast hospital and I can say that these findings are not surprising. However, the paper doesn’t necessarily answer all the questions that we may have about correlations with boarding time. It starts to ask some of the additional questions that we would like to see answered as we are continuing to implement these measures. Studies like this could make us think about what we do with this measure: for example, if we use it just in a public reporting sense or tie it to payment. But at the end of the day, we still think of boarding as an important measure. THIS PAPER CAME OUT OF A GROUP OF RESEARCHERS WHO WERE AFFILIATED WITH THE EMERGENCY CARE COORDINATION CENTER (ECCC). SO HOW DOES THIS STUDY FIT INTO THE MISSION OF THAT PROGRAM? Carr: Thanks, Dr. Meisel, for putting together this dialogue. This paper touches on our priorities in a number of ways. For those who don’t know, the ECCC is located in the office of the Assistant Secretary for Preparedness and Response (ASPR) at the U.S. Department of Health and Human Services (HHS). ECCC’s focus is on day-to-day emergency care, and we often approach this from the perspective of how day-to-day emergency care is tied to preparedness and our ability to respond. The Assistant Secretary, Dr. Lurie, is fond of saying that we recognize that true preparedness requires an emergency care system and health care system that is highly functional and high quality every day. There are four key components to our mission: 1) lead the way into a patient- and community-centered emergency care system, 2) make sure that the system we build is integrated
572
into the larger system (we don’t think that emergency care should be a carve-out), 3) build a system of emergency care that is high quality, and 4) make sure that the emergency care system we are building makes us more prepared and ready to respond in a time of local or national need. I think this paper touches on all of these. It is very easy for me to see that boarding is a patient-centered outcome. It is also very easy for me to see that there is a community tie—our goal shouldn’t just be to determine if our hospitals are crowded, but if ALL of our hospitals in a community are crowded. This paper starts to shine a flashlight a bit on the geography issues here: it suggests that the Northeast has more of a problem with boarding than other regions of the country. A few people on the call deserve kudos for long-standing work changing the way that crowding and boarding is seen— pushing the world to understand that crowding is a hospital problem, not an ED problem. At the end of the day, it doesn’t matter if it is my family member or my neighbor lying in the hallway for hours—either way, we can do better. I would also argue that we should think about boarding from a preparedness perspective. And I would point interested parties toward a National Quality Forum (NQF) report a few years ago that created the tie between boarding and regional preparedness. When we look at this paper, we see that high-volume hospitals in the Northwest have the worst boarding problems. They are also at risk for natural disasters like flooding as we saw in Hurricane Sandy and man-made disasters like the Boston bombing. Their tremendous day-to-day crowding could present a real challenge when they need to surge to meet the demand for services created by disasters. ARE THERE SOLUTIONS TO BOARDING AT SPECIFIC HOSPITALS? Pines: There are local solutions that can effectively improve the boarding measure within individual hospitals. These issues are sometimes due to capacity—particularly in critical care units. But what goes into smoothing the transition to inpatient beds has less to do with capacity and the administrative work and culture within hospitals that allows patients to sit in the ED for a long time. Often the incentives are all misaligned. Boarding is worse in places that are an “us vs. them” culture—where units don’t work together to solve hospital-wide problems. I think a lot of this is addressable at a local level. There is a performance gap and Steve’s study reinforces that. There is variation across the country. Carr: I do think that a piece of this problem is that “we” the emergency care community, “we” the primary care community, and “we” the health system administration—don’t really know what “we” want the emergency department to be. So I get Jesse’s point that the system issues might be addressable but it makes me wonder to what extent the system believes that it is important to fill a bed with an ED patient. I am often frustrated by ongoing language around “inappropriate” use of the ED and whether people
Meisel et al. • ED BOARDING & HOSPITAL QUALITY
ought to be there and whether people should be going through the ED to get to the hospital. This dialogue is difficult because it points to the three different systems that are being built. The first is a backup to the primary care system—it’s a place to see patients with exacerbations of chronic illnesses that diagnoses them, treats them, and sends them home with a plan to go back to their usual source of care. The second is a conduit to the inpatient setting hospital. Fifty percent of admissions [note: 80% of unscheduled admissions] come through the ED these days and many outpatient providers without inpatient privileges refer patients in to be evaluated because they think they may end up requiring admissions. And the last is the caricature of the ED that we see on TV—the focus on life and limb threats. We need to better articulate how we want acute care in the U.S. to be managed— because if we can do that, the systems can fix themselves. We will no longer see management that is efficiently building one of these three systems while patients and providers are hoping for a different end result. We need to set a goal that we can race toward. CMS has said that they want to align incentives in a clear way so that people can innovate to get over the finish line. ISN’T THIS OBVIOUS THAT THIS IS A PROBLEM WHEN WE CAN’T TAKE CARE OF PATIENTS WITH LIFE AND LIMB THREATS WHEN THE ED IS CLOGGED WITH INPATIENTS? Pines: As we move to models that emphasize value over volume, it might lead to patients spending more time in the ED because it may be more efficient, for example, to get an MRI for a neurology patient in the ED and discharge after it is negative than to admit them for 2 to 3 days. Carr: I think he is right that we are going to see longer ED visits because we are doing inpatient workups in the ED. People are not talking about this in the right frame yet. In other words, you can go to the ED to get in 8 hours what used to be a three-day admission. People are still talking about going to the ED as the “wrong” place compared to your usual place of care. But it’s being used for something different and we haven’t built capacity for that. TO WHAT EXTENT THIS CONCEPT OF LARGEVERSUS SMALL-VOLUME HOSPITALS AND ITS RELATIONSHIP WITH BOARDING IMPACT THE WAY CMS THINKS ABOUT THIS PROBLEM? Goodrich: One of the things that I’ve been thinking since I read this paper and during this conversation is that maybe we need to look at large- compared to small-volume hospitals. When we see poor performers move into medium- or high-performing ranges that is good. So what would be interesting is to understand if there is variation within the high-volume hospitals or if everyone with high volume has long ED boarding times. In other words, is this just such a huge problem in all high-volume hospitals that there may not be an opportunity for improvement?
ACADEMIC EMERGENCY MEDICINE • May 2014, Vol. 21, No. 5 • www.aemj.org
So for me that would be one of the next questions that would be interesting to answer. I don’t think that what we’ve been talking about here and what Steve Pitts found in his study would necessarily lead CMS to remove the boarding measure. We still think it is a critically important concept. But it certainly piques our interest in following the literature to see how we could improve upon the measure because I think this is such an important patient-centered construct. As Brendan said, we want to get to the right outcome, we don’t really care how hospitals go about doing it as long as patient care isn’t compromised. We think this is an important outcome in particular for patients. So we will follow where the literature takes us in learning more about this important measure. SO CAN WE FIND THE POSITIVE DEVIANTS AND OUTLIERS SO WE CAN LOOK AT THIS PROBLEM WITHIN CATEGORY OF HOSPITAL? Carr: It is really interesting to me to think about how to build a system of incentives and maybe measures that allow people to innovate not just within their facility— but within their community. From my perspective, when a giant hospital goes down in NYC, if every other hospital is terribly crowded, it really is important to think about how we might safely find a place for those patients to safely go. So if our goal is only to talk at the hospital level about the ability to move patients rapidly into their inpatient units, is that enough? I don’t know. If I am a member of a community, I want more. I would want hospitals that compete every day for their referral care, to cooperate when it comes time to manage a surge. This is what patient- and community-centered care is. Zachary F. Meisel, MD, MPH, MSc ([email protected]) Center for Emergency Care Policy Research Department of Emergency Medicine Perelman School of Medicine Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia, PA Stephen R. Pitts, MD, MPH Department of Emergency Medicine Emory University Atlanta, GA
573
Jesse M. Pines, MD, MBA, MSCE Emergency Medicine and Health Policy George Washington University School of Medicine and Health Sciences Washington, DC Kate Goodrich, MD, MHS Centers for Medicare and Medicaid Services Baltimore, MD Department of Medicine George Washington University School of Medicine and Health Sciences Washington, DC Brendan G. Carr, MD, MA, MSc Center for Emergency Care Policy Research Department of Emergency Medicine Perelman School of Medicine Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia, PA Emergency Care Coordination Center Office of the Assistant Secretary for Preparedness and Response U.S. Department of Health and Human Services Washington, DC
Supervising Editor: David C. Cone, MD.
Reference 1. Pitts S, Vaughn FL, Gautreau MA, Cogdell MW. A cross-sectional study of emergency department boarding practices in the United States. Acad Emerg Med 2014;21:497–503. Supporting Information The following supporting information is available in the online version of this paper: Data Supplement S1. Audio file of roundtable discussion.
