By Stacey Kusterbeck
Boarding is a common occurrence in most emergency departments (EDs). However, it has been studied more often in adult EDs than pediatric EDs. “Boarding has been thought of historically as a problem primarily of adult EDs, not pediatric EDs,” says Brandon Kappy, MD, a pediatric emergency medicine fellow at Children’s National Hospital in Washington, DC.
Until recently, boarding in pediatric EDs was not as prevalent or severe. “With recent respiratory viral surges coinciding with a national acceleration of the closure of inpatient pediatric units, pediatric EDs and hospitals have become increasingly crowded — leading many to perhaps experience boarding for the first time,” Kappy explains.
Once an admission decision is made, it has been determined that the best location for the pediatric patient is on the floors or in the intensive care unit (ICU). “Boarding the patient in the ED while there continues to be an influx of new patients can lead to delayed care or initiation of needed treatments for the boarded patient,” warns Jonathan M. Fanaroff, MD, JD, a professor of pediatrics at Case Western Reserve University School of Medicine in Cleveland. Spending hours in the ED waiting for a bed assignment results in frustration for both the patient and family. “Unsatisfied families may be more likely to pursue litigation, should an adverse outcome occur,” he says.
Isolation and lack of other activities while boarding can lead to delays in access to certain resources, evaluations, or treatment, says Katherine Remick, MD, FAAP, FACEP, FAEMS, co-director of the National EMS for Children Innovation and Improvement Center and associate professor of pediatrics and surgery at the University of Texas at Austin. “It also has the potential to worsen medical and/or mental illness, or exacerbate underlying feelings of hopelessness and anxiety,” she adds.
Kappy and colleagues conducted a study to find out how medical and surgical boarding has changed since the COVID-19 pandemic, how inpatient service designation affects boarding times, and how boarding affects hospital length of stay (LOS) and patient safety events.1 They analyzed pediatric ED boarding at Children’s National from 2018 to 2022. Boarding increased steadily during that time frame, for both acute and critical admissions. “The substantial degree to which it increased since July 2021 was notable,” Kappy reports.
Boarding increased for every patient demographic, diagnosis, and day and time of arrival in the pediatric EDs. “No subgroup was disproportionately responsible for observed increases in boarding times,” Kappy notes.
Longer boarding times were associated with longer hospital LOS for acute care (non-ICU) admissions. “This has important implications for the current crowding crisis,” Kappy says.
The association between boarding and increased LOS suggests a self-perpetuating cycle, according to Kappy. Longer inpatient stays reduce available hospital beds. In turn, that worsens boarding by preventing newly admitted pediatric ED patients from moving out of the ED into inpatient units. Boarding reduces available ED beds and occupies staff that otherwise could be dedicated to newly arriving ED patients. “Pediatric and adult ED providers should be aware of the potential impacts that boarding can have on the broader flow of the ED, as well as how it impacts individual patients,” he says.
Acute care boarding was associated with patient safety risks for ED patients. There were higher odds of an adverse event report during periods of boarding. Some reports were related to care delays, which would be expected due to increased boarding. Others were related to issues such as laboratory labeling errors. This suggests that prolonged ED boarding times may place patients at higher risk for certain types of adverse events. “With this knowledge, providers can try to implement additional measures to minimize patient safety risks in boarding populations,” Kappy offers.
ED staff should be aware that boarding patients may be at higher risk of safety events. “EDs should reinforce existing preventive measures and determine if boarding patients require new safety protocols while in the ED, which they had not needed to previously consider,” Kappy advises.
REFERENCE
- Kappy B, Berkowitz D, Isbey S, et al. Characteristics and patient impact of boarding in the pediatric emergency department, 2018-2022. Am J Emerg Med 2023;77:139-146.
Boarding is a common occurrence in most EDs. However, it has been studied more often in adult EDs than pediatric EDs.
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