Emergency Department Boarding: Methods Accounting for Lost Productivity

Boarding admitted patients in an emergency department (ED) represents one of the greatest challenges to emergency care in the United States. The Institute of Medicine in 2006 recommended an end to boarding admitted patients within EDs. Subsequent research has established adverse implications of ED boarding on patient quality outcomes. However, since 2010, the average ED length of stay for an admitted patient, including boarding time, has increased from 281 minutes to 304 minutes.

Effective hospital leadership monitors a variety of metrics regarding ED quality, throughput, and staffing efficiencies. While alternative productivity calculations exist, such as the use of Ambulatory Payment Classifications, most US EDs calculate productivity by using a unit of service called worked hours per patient visit (wHPPV), where total productive staff hours are divided by the number of patient visits. Boarding patients present a challenge when interpreting wHPPV. These patients require additional staff resources than the typical ED patient due to their prolonged time in the ED and acuity. For this reason, it’s prudent to have a method to account for boarding patients. Without this, EDs may appear less productive, resulting in less human capital than necessary to provide care.

Little to no research has evaluated standardized methodologies to account for the productivity impact of admitted patient boarding. The challenge with using the wHPPV model in relation to boarding is the lack of consideration for a patient’s acuity and length of stay, as each patient, regardless of those factors, counts as one visit. This paper provides insight into the challenges associated with properly measuring for boarding patients’ impact on ED productivity; it also discusses the impact of four methods on accounting for such loss.