It is no secret that emergency departments are overwhelmed. Hospital emergency departments have been battling high volumes of patients with limited resources even before the COVID-19 pandemic. Patients wait in the emergency department even after they have been admitted as an inpatient because there are not enough inpatient rooms or personnel to staff the units. This is called emergency department boarding. You are being boarded in the emergency department, but the emergency doctors are no longer responsible for your care.
Let’s put ourselves in a scenario of how emergency room boarding could cause a medical error.
You brought your 70-year-old mother to the emergency department (ED) because she was having a headache. She was brought back right away. The triage nurse checked her vital signs, and a physician came to see her in the triage room. It was determined that mom needed a CT of her head. She was taken back fairly quickly to the radiology department and shortly after the doctor told you that the CT was normal.
After the CT, your mother was placed in a stretcher that the nurse parked in the hallway because there were no emergency rooms available.
Another doctor came to see your mother and determined that she will be admitted so that they could run some additional tests and monitor her condition.
Your mother has technically been admitted and considered an inpatient but continued to stay in the ED. This is called emergency department boarding.
What could be so bad about that? Your mother is in the emergency department, those doctors are equipped for everything!
The problem is the emergency medicine doctors are no longer overseeing her care. The admitting doctor is in charge of her care. You know, the one who barely introduced himself in the hallway and said that your mother would be going upstairs? There was not time to even catch his name.
The one nurse caring for your mother was being pulled in many directions in the busy ED and has not come by in a while.
Rather quickly, your mother’s condition changed. She seemed pretty drowsy and weak; although she had been given some medications. She was unable to help herself up out of bed to go to the bathroom. You called for the nurse. The ED nurse was overwhelmed with her emergency patients and asked the patient care tech (PCT) to assist your mother to the bathroom.
The PCT noticed that your mother was having trouble using her right side to push up out of the bed. The PCT did not record in the medical record that there were any difficulties assisting your mother and did not say anything to the nurse. You thought that your mother was just a little wobbly from the medicine that she was given, and you did not give it much thought.
About 6 hours later, your mother finally gets transported from the ED to her inpatient room.
Your mother was getting moved from the stretcher to the hospital bed and the admitting nurse noticed that she was unable to move her right arm or leg at all. The nurse called a rapid response, which alerts a team of doctors and nurses to assess a change in patient’s condition. The team determined that your mother had a stroke. The blood supply to her brain was being blocked by a blood clot.
Unfortunately, too much time had passed to give her a medication called tissue plasminogen activator (TPA), that is used to break down blood clots. TPA is recommended to be administered 3-4.5 hours after onset of stroke symptoms.
This delay in time in recognizing the right sided weakness in the emergency department hallway resulted injury to the brain which left your mother with permanent functional impairments.
Those patients that are boarding in the emergency department are vulnerable because they do not receive the same level of care as they would being admitted to the floor. Several studies showed that emergency department boarding increased ventilator-associated pneumonia, critical care unit mortality, and overall admission.
Emergency department boarding was discussed in an article published in the Journal of the American Medical Association (JAMA). Emergency department boarding refers to holding admitted patients in the ED, often in hallways, while awaiting an inpatient bed. The Joint Commission identified boarding as a patient safety risk that should not exceed 4 hours.1 Downstream harms include increased medical errors, compromises to patient privacy, and increased mortality.2 Boarding is a key indicator of overwhelmed resources and may be more likely to occur when hospital occupancy exceeds 85% to 90%.3
Leave a comment and let me know if you have any stories or questions about emergency department boarding leading to medical errors: