Boarding Inpatients in the Emergency Department Increases Discharged Patient Length of Stay

Background

Boarding of inpatients in the Emergency Department (ED) has been widely recognized as a major contributor to ED crowding and a cause of adverse outcomes. We hypothesize that these deleterious effects extend to those patients who are discharged from the ED by increasing their length of stay (LOS).

Study Objectives

This study investigates the impact of boarding inpatients on the ED LOS of discharged patients.

Methods

This retrospective, observational, cohort study investigated the association between ED boarder burden and discharged patient LOS over a 3-year period in an urban, academic tertiary care ED. Median ED LOS of 179,840 discharged patients was calculated for each quartile of the boarder burden at time of arrival, and Spearman correlation coefficients were used to summarize the relationship. Subgroup analyses were conducted, stratified by patient acuity defined by triage designation, and hour of arrival.

Results

Overall median discharged patient ED LOS increased by boarder burden quartile (205 [95% confidence interval (CI) 203–207], 215 [95% CI 214–217], 221 [95% CI 219–223], and 221 [95% CI 219–223] min, respectively), with a Spearman correlation of 0.25 between daily total boarder burden hours and median LOS. When stratified by patient acuity and hour of arrival (11:00 a.m.–11:00 p.m.), LOS of medium-acuity patients increased significantly by boarder burden quartile (252 [95% CI 247–255], 271 [95% CI 267–275], 285 [95% CI 95% CI 278–289], and 309 [95% CI 305–315] min, respectively) with a Spearman correlation of 0.18.

Conclusion

In this retrospective study, increasing boarder burden was associated with increasing LOS of patients discharged from the ED, with the greatest effect between 11:00 a.m. and 11:00 p.m. on medium-acuity patients. This relationship between LOS and ED capacity limitation by inpatient boarders has important implications, as ED and hospital leadership increasingly focus on ED LOS as a measure of efficiency and throughput.