December, 2017
By Charles A. Pilcher MD FACEP
Emergency Departments around the country are crowded. Implementation of the Affordable Care Act was anticipated to reduce the use of the ED, but that has not happened, likely due to a shortage of primary care physicians. While most ED’s are able to manage a sudden influx of patients well, all experience the occasional overwhelming “surge.” Multiple solutions to coping with high patient volumes have been implemented involving additional staffing, physician triage, fast-track sections of the ED, etc., but one of the biggest hurdles to overcome is that of “boarding.”
The American College of Emergency Physicians defines boarding as “the practice of holding patients in the emergency department after they have been admitted to the hospital, because no inpatient beds are available.” Admitted patients need care beyond that able to be provided in the ED, or else they would not be admitted. Boarding results in fragmented and delayed care with the risk that either no one is in charge or the wrong caregiving team is in charge. The ED is excellent at stabilizing a pediatric patient with breathing difficulty due to pneumonia or bronchiolitis but stability may be temporary. Those kiddos need a pediatrician, a respiratory therapist, pediatric trained nurses and perhaps even a pulmonologist. Boarding them in the ED because there is nowhere else to put them puts them at risk for deterioration.
According to ACEP, boarding “has been shown to have an adverse impact on patients, with longer delays causing greater morbidity and mortality.” This also increases the chance of a lawsuit if boarding leads to patient deterioration. An example of this that led to a lawsuit is that of a 4 yo child with signs and symptoms of meningitis, so he was admitted to the hospital He was seen by a pediatrician in the ED, but left there awaiting an inpatient bed. An order was written by the pediatrician for antibiotics, but the pediatrician expected that the child would be “going upstairs” soon and was unaware that a bed would not be available for several hours. Since the order was written on the patient’s inpatient chart, the ED staff never saw it. The ED doc believed the patient was the responsibility of the pediatrician and the pediatrician assumed that his order for antibiotics would be carried out by the ED staff in the event of any delay. After several hours the patient was obviously worse. When the patient experienced a poor outcome, a lawsuit was filed., eventually resulting in a plaintiff verdict.
This case has been presented to physicians as a case of a fumbled “handoff,” but the root cause is that of overcrowding and boarding. Lawsuits related to both of these are not uncommon. Almost every med mal case related to the ED includes a check of the patient log to see how busy the physician was when an alleged error occurred. But the number of boarded patients in the ED at any one time is also a factor in stretching the capabilities of each member of the ED team.
Psychiatric patients and others with behavioral disturbances are the biggest single source of boarded patients. This is the result of several factors such as:
- laws that require the signature of a designated mental health professional (MHP) for an involuntary hold
- a shortage of MHP’s and delays in their availability
- a shortage of inpatient resources for the mentally ill
- an increase in drug and alcohol related mental health disorders
These patients often deteriorate because the MHP ideally wants to evaluate patients in their “original” state, not after they have been treated with medications that may have made them (temporarily) no longer a danger to themselves or others. This also often leads to the prolonged use of mechanical restraints, which also increases the risk to patients – and staff.
Any attorney evaluating a malpractice case that might involve overcrowding or boarding should be familiar with resources available through ACEP that address the issue. Examples include: