Critical Care Boarding in the ER: Complicated Problem, Bad Outcomes

Written by Aaron Lacy

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ED boarding of critically ill patients is common and is associated with worse clinical outcomes: increased duration of mechanical ventilation, increased probability of poor neurologic outcome, longer ICU length of stay, and higher in-hospital mortality. This a systemic problem with no easy fix.

Why does this matter?
Although definitions vary, ED boarding is both harmful to patients and widespread. There has been an 80% increase in ED visits for critically ill patients (2006-2014), with a minimal growth in ED capacity or inpatient ICU bed space. You will be taking care of a critically ill patient in the ED at some point, and understanding the causes, limitations, and mitigation efforts will help patient care.

SORRY, NO VACANCY
A task force set out to answer three questions related to boarding of critically ill patients in United States emergency departments. 18 retrospective and prospective studies were used to collect the information needed.

What is the frequency of critically ill patients boarding in the ED?

  • There is no accepted universal definition of ED boarding, and estimates for ED boarding incidence range from 2.1 – 87.6%. Some use time metrics (2,4, or 6 hours) while others use total numbers of hours an intubated patient spends in the ED.

  • From 2006 – 2014 ED visits for critically ill patients increased by 80%, and intubated patients in the ED increased by 16%.

  • Over 250,000 patients a year receive mechanical ventilation in the ED with a median LOS greater than 3 hours.

What are the outcomes associated with critically ill patients boarding in the ED?

  • ED boarding is associated with increased duration of mechanical ventilation, longer ICU length of stay, higher mortality, and four-fold increase in probability of poor neurologic recovery in stroke patients.

  • ED boarding also lends itself toward low-quality process-related care of the critically ill, including post-intubation elements, delays in home medication initiation, fluids, antibiotics, and disease-specific protocolized care.

  • ED boarding affects the care of other ED patients secondary to resource allocation.

  • There is particular concern with patients who are declined ICU admission and then must be “stabilized” to meet the requirements for a floor bed. This leads to substantial increases in boarding times (11.7 vs 4.2 hours).

What are some mitigation strategies to decrease the impact of critically ill patients boarding in the ED? 

  • ED solutions: Targeted interventions to improve pain and agitation management, vent management, more frequent hemodynamic assessments, infection prevention and targeted resource utilization can be used to improve both critically ill and general ED patient disposition and care. Using models to predict when a surge may happen based on waiting room status, hospital capacity, and retrospective review of trends may help plan for ED critical care boarding.

  • Hospital Solutions: ICU alert teams have been deployed to the ED to take care of boarding ICU patients. Good interdepartmental collaboration to help move patients laterally from one ICU to another in the same institution, and priority placement of ICU patients being transferred to the ward (as opposed to new ward patients from the ED getting those beds) can help. Other ways to offload hospital capacity include “discharge waiting rooms” for low acuity patients who have been discharged and are waiting on pharmacy/paperwork/rides etc. Stepdown units can play a role in allowing sick patients who are not crashing to receive the higher level of care necessary while keeping ICU beds open.

  • ED Resuscitative Care Units: Several centers across the U.S. use critical care units in the ED to directly address critical patients boarding. Observational data from one center that employs this model showed 15.4% reduction in risk-adjusted 30-day mortality among all ED patients, and reduction in hospital and 24-hour mortality. ICU admission fell 12.9%, and ICU length of stays less than 24 hours fell by 37.1%. Patients overall received ICU-level care faster. Comparative studies from the other institutions practicing this have yet to be published.

A key statement was: “ED boarding reflects symptoms of a systemic healthcare problem with multiple downstream effects; it is not simply a failure of ED operations.”

While this study did not directly address the type of centers most effected, working at a large tertiary and academic referral center I often feel the pressures and effects of ED boarding, and I am sure that I’m not alone. This will take a massive overhaul of our healthcare system to fix. But understanding and defining the problem is an important first step.

Source
Boarding of Critically Ill Patients in the Emergency Department. Crit Care Med. 2020 Aug;48(8):1180-1187. doi: 10.1097/CCM.0000000000004385.

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