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The Real Risks of Boarding in the Emergency Department

December 15, 2023

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Written by Amanda Mathews

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In this large, multicenter prospective cohort study in France, researchers found that patients ≥75 years who were admitted overnight boarding in the ED had higher rates of in-hospital mortality, length of stay, and adverse events.

The real risks of boarding
This study cohort included 97 Emergency Departments in France across a 48-hour period in December 2022. All patients ≥ 75 years who were ultimately admitted to the hospital ward were included in the study, totaling 1,598 patients. Patients were split into two groups: those who spent the night (midnight until 0800) admitted in a bed in the ED versus those who were admitted to an inpatient ward before midnight. Patients were followed through hospital discharge or for up to 30 days. In France, boarding patients in the ED are managed by the ED team. Primary outcome was in-hospital mortality.

Median length of ED stay before admission was 23 hours in the ED group and 7.5 hours in the ward group. 80 patients stayed in the ED for two days prior to ward admission. There was a higher in-hospital mortality rate among the ED group (15.7%) compared to the ward group (11.1%), aRR 1.39 (95%CI 1.07-1.81), and a higher risk of adverse events: 30.4% vs 23.5%, aRR 1.24.

This study was limited by the time course of its data collection, with December 2022 being a particularly busy time for ED care with COVID/flu/RSV. Multiple confounders were not taken into account including overall ED volume, race, ethnicity, and social determinants.

How will this change my practice?
We’ve all seen an elderly patient laying in a hallway bed overnight, and it causes many providers moral injury. While it is difficult to affect institutional change on a single shift, this study provides data about long term harms that can occur to our vulnerable elderly population if left boarding in an emergency department for long.

Editor’s note: Table 1 shows higher volume EDs had more boarders. In a busy ED, sometimes it’s all we can do to simply keep up with new arrivals. Throw in the care of numerous admitted boarders, and something has to give. How would this turn out if the inpatient team came down and managed boarders instead of the emergency physicians who were already stretched? ~Clay Smith

Overnight Stay in the Emergency Department and Mortality in Older Patients. JAMA Intern Med. 2023 Dec 1;183(12):1378-1385. doi: 10.1001/jamainternmed.2023.5961.

What are your thoughts?