Episode 7: Boarding

Boarding is the absolute worst. Let's talk about it! If you get as upset as I am, I've done my job.

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Transcript

Hello and welcome to Inside the ER. My name is Dr. Padraic Gerety and I’m a practicing, board certified emergency physician.

You’re joining us today for our seventh episode, entitled “Boarding.” This is not Keanu Reeves and Patrick Swayze in Point Break boarding, this is sitting in the ER for an inordinate amount of time boarding. Today we’re going to discuss what it is, why it stinks, how it happens, and if we can do anything about it.

Before we begin I’m not going to outright ask you to listen to our previous episodes if you haven’t already…but it would be nice if you did. Nor am I going to ask you to help spread the word about the show…but it also would be nice if you did.

If you’ve never seen the aforementioned 1991 classic film Point Break, then I AM going to ask, no demand, you watch it after you listen to this episode. Then be sure to write in at insidetheer@gmail.com and tell me how great it is. Do NOT watch the terrible and pointless 2015 remake.

Anyway, in our last episode, number 6, we talked about transfers and I said that was the last option for how patients are dispositioned in the ER. That’s pretty much true, except for this ugly beast.

Boarding is the limbo, or better yet, the purgatory of dispositions. It is the ugly duckling, except it has no redeeming qualities and will not grow up to be a swan. The American College of Emergency Physicians, or ACEP, defines boarding as when a patient “remains in the emergency department after the patient has been admitted or placed into observation status at the facility, but has not been transferred to an inpatient or observation unit.” This is similar to my own definition I gave in episode 4, when I said that “boarding is when a patient is technically admitted to the hospital as the hospitalist has accepted the admission but there is no inpatient bed available.”

I’m realizing now that I need to adjust the definition because boarding doesn’t just apply to admission. Boarding is when a patient sits in the ER for any extended period of time because their final destination isn’t available yet. 

So a patient can be boarding because they’re admitted and waiting for a bed upstairs, right? Sure. They can also board because they’re waiting for a bed to be available at another hospital or psychiatric institution they are being transferred to. 

There are also social work boarders in the ER. This may require its own episode one day. But briefly these patients do not have an emergent medical condition requiring admission, ya know technically they could be discharged but there is a social situation preventing that discharge home. This is often, I see an elderly person for a fall. They have no acute medical condition or serious injury from the fall, but their chronic weakness or falling has gotten worse and the family is concerned it is not safe at home any longer. So now I have to enlist the help of social workers and physical therapists to figure out a safe discharge. That safe discharge may be back home with home health set up or even to a facility like an assisted living or rehab. That takes time, often days, and the patient is boarding until it’s figured out.

So, as you can see…or hear I guess haha… there are several reasons one can board in the ER. So what, who cares, you say? Nah no, not so what, boarding sucks and I refuse to let anyone trivialize that! You should care cause this could happen to you or your family, so listen up! Sometimes people board for not hours but days. This severely strains the ER in terms of space and workforce, negatively impacting existing patients, new patients, and our staff.

On a busy day, I can walk in, look at the board, as in the screen showing all the patients in the ER, and find that we are full of boarders. I mean full. Everyone is waiting for a bed upstairs, to be transferred, or for a social work solution. Then, I turn to look at the waiting room board and see it’s full of boarders too! As I said in episode 4, when boarding is really bad, then it extends out to the waiting room. People are technically admitted, as in the inpatient team accepted the admit and put in orders, but they’re still sitting in the waiting room. We are kidding ourselves if we believe these patients can get more than a fraction of the care we hope to provide.

If you’re boarding in an ER bed, then that’s clearly better than the waiting room, but it’s still not great. The ER is NOT designed to care for patients, especially sick ones, for long periods of time. The overstrained ER staff can simply not keep up with all the orders for active ER patients and boarding admitted ones too. Upstairs, or inpatient, nurses have nursing ratios, as in a maximum number of patients they are expected to care for, but no such thing exists in the ER if a sick patient comes in.

We can go on alert where we ask ambulances to avoid us if possible, but that only does so much. If a sickie comes in, ESI 1 or 2. Wait…ESI, do you remember that? No? Go relisten to episode 2!  Ok actually when a sickie comes in, cause they always do, they have to be seen. The only way to do that on a busy day is to pull resources from someone else. ER is a game of spinning plates, you know some of them will fall and you just hope they don’t break. 

Now don’t just take my word for it that boarding is awful, here’s a quote from the Joint Commission: “ED boarding is associated with delayed and missed care, medication errors, delirium, higher morbidity and in-hospital mortality, and longer hospital length of stay as well as poor patient satisfaction.”

The Joint Commission, for those lucky enough not to know, is basically the boogeyman of the ER and hospitals in general. It’s this nonprofit organization that terrorizes us a few times a year with the threat of revoking our accreditation because someone left a sandwich out or something. They conducted surveys last year that confirmed the obvious, boarding pisses people off, patients and staff alike. So much so that ER providers note a large uptick in verbal and physical abuse from boarding patients. Ahhh, it’s nice to be appreciated, ya know?

I even found one study suggesting that not only does an admitted patient spend longer in the hospital if they board in the ER first, but that EVERY admitted patient, even those who didn’t have to board, spends longer in the hospital if there’s significant boarding that day.

It’s time for a break, we’ll be right back after a word from our sponsor.

Are you currently boarding Inside the ER? Or worse yet, boarding…in the waiting room? If so, that’s dreadful, I’m sorry, but please take heed of today’s sponsor: don’t harass the ER staff! Yes, boarding is terrible for so many reasons, but guess who’s to blame? Not us. When will I get a bed upstairs you ask? We have no idea. When will I get transferred out? We have no idea. Some people yell at any available face when they’re upset, even though we have nothing to do with the boarding. So before you do, hold your tongue and ask yourself, am I screaming to fix the situation or just to make someone else feel bad?

Now, back to the show:

All right, all right, you must be saying, I get it, boarding is the worst. But why does it happen? In a nutshell, overcrowding and understaffing. We’ll start with the biggest reason, overcrowding. There are simply too many patients coming in, and the system just can’t accommodate them. Why so many ER patients? All the reasons you’d expect. 

First an aging population. People are living longer and those old folks need the ER more often. Second, no health insurance! The uninsured have nowhere else to go. Third, no beds at psychiatric units! Patients with psych emergencies are forced to come to the ER and spend not hours, but days and days, boarding. And fourth, over-reliance on the ER. Coming to see me as if I’m your primary care physician or OB/GYN is just too convenient.

Keep this in mind the next time you consider venturing to the ER for a non-emergency. Perhaps it’s flu season, a Monday after a holiday weekend? That’s a total disaster waiting to happen. Remember friends! If you think one day is the most convenient for you to go to the ER, then a lot of other people will be thinking the same thing. 

Overcrowding of course affects transfers as well. As I said last episode, transferring can be a nightmare, often because the receiving hospitals are already overcrowded, full, boarding on their own. They can’t even treat the patients they have, they’re not taking my patient despite the brain bleed. I often find myself getting my patient accepted for transfer but there isn’t actually a staffed bed available yet. So, my patient boards in a setting that is wholly inadequate for their needs. In consultation with a specialist, we will do the best we can to stabilize and we can only hope the boarding doesn’t last too long. 

The second main reason for out of control boarding is understaffing. Simple, it’s nurses! Just because there’s an empty bed doesn’t mean there’s a nurse for it. We’ve got a nursing shortage in this country, so much so that certain hospitals will pay big bucks to entice traveling nurses. Some hospitals can’t or won't keep up with this and the patients suffer. 

What do I mean by won’t? Well, there are plenty of hospitals that can’t hire more nurses because they’re underfunded and work with an underserved population. But…there are also hospitals that won’t hire more nurses. Healthcare is a business in the US, and the more money you spend on nursing, the less money you have for profit. Every hospital administration has to make a decision: do we enrich ourselves or do we hire adequate staff? The hospitals that choose profits over patients exploit the altruism of their clinicians by making them do more with less.

These administrators know that doctors and nurses feel a moral imperative to help patients, and will keep returning to work despite unsafe conditions. I don’t mean like the hospital is flooding unsafe, though one time in residency one of sinks in the Peds ER began overflowing with sewage…that was gross. No I mean situations where the overcrowding and understaffing are so bad that patient safety is at risk. Now, if a patient has a bad outcome, do you think hospitals rush to defend their clinicians? Don’t bet on it.

I’ve heard there are hospitals where when the boarding is out of control, the administration might hint at the ER providers to reduce their admissions. Basically, they’re saying, “the hospital is full, try not to admit anyone.” Yeah, sure, you don’t want to contribute to overcrowding, except practicing medicine doesn’t really work like that, now does it? Short of a literal mass casualty event, an ER provider shouldn’t decide how treat a patient based off of how busy the hospital is or what’s happening to other patients. You’ve gotta treat the patient in front of you.

ER providers do what they think is necessary for the patient regardless of how busy it is. So, they’re not gonna say to you, “You need to be admitted but I’m not going to because we’re just too busy,” unh uh, but they can do what I do: tell the truth. I make a point to tell patients the truth, as uncomfortable as that can be. Is that mass we found on your CT scan cancer? I can’t prove it with 100% certainty without a biopsy, but if it’s very suspicious, I’ll give it to you straight. When patients ask me if something is going to hurt, I say yes. Of course, they know it’s a yes. They wouldn’t ask me that question if they knew it wasn’t. Sorry y’all, pain is part of life, it sucks, but it is.

So when I admit you from the waiting room on a very busy/overcrowded/board-happy day, I will tell you the truth about what’s in store. “Hey, I need to admit you but it’s very busy and we’re boarding a lot of patients. In fact, there are already other people who are technically admitted but also boarding in the waiting room like you are now.” 

Usually in these cases I can not give an accurate estimate as to when an ER bed, much less an inpatient bed, will be available. There are too many moving parts. An ES1 level 1 patient could roll in any minute and bump everyone else for the next bed. 

Now before the government comes after me, I am NOT discouraging you from being admitted by letting you know about the boarding situation. I’m just giving out important information and refuse to lie by omission. We of course have to be careful about how we say this because any unreasonable person can cause trouble by claiming an EMTALA violation. 

So what can you as a patient do about boarding? Well first off ask yourself if you really need the ER or will an urgent care do? If you do need the ER consider what hospital you are going to if you’re going to need any speciality care. Third, as I said in episode 4, prepare to be admitted by bringing supplies! An extra layer, a book, a phone charger, earbuds, a list of your meds, but that’s not all. You may be forced to sleep in an ER bed with patients screaming and machines beeping all around you, so might as well bring a facemask and ear plugs! And lastly, if possible bring someone with you who can ask questions and advocate for you without harassing the staff.

The last thing I’ll say is that everyone hates boarding. It’s frustrating and unsafe. But guess what, none of the staff you can see in the ER has anything to do with it. All us ER staff can do in the moment is stay vigilant and work hard. What you can do as patients is share what you’ve learned, direct people to this episode, and help raise awareness so those in power recognize the danger.

That’s it for this episode, we’ll be back in two weeks, ish. Yes, two weeks-ish. We’ve got a family addition coming soon and it may get in the way!

If you liked the episode, please follow, subscribe, download, leave a 5-star rating, and tell EVERYONE YOU KNOW. If you didn’t like it, feel free to keep listening at high volume to annoy your family and tell everyone you know to do the same.

You can send in your comments and let me know how much you hate boarding to insidetheer@gmail.com. 

Thanks for listening and all the best.