At 3 a.m. last Tuesday, I had 41 patients in an emergency department built for 28. Nineteen of them had already been admitted to the hospital. They were waiting for a bed upstairs. One of them, an 84-year-old man with pneumonia, had been on a stretcher in our hallway for 51 hours.
This is called boarding, and it is the thing that is breaking emergency medicine. Not the gunshot wounds, not the overdoses, not the violence. The waiting.
What boarding looks like
A boarded patient is technically admitted. They have a team upstairs that writes their orders. But they are physically in the emergency department, under fluorescent lights that never turn off, next to a nurse who is also caring for four other patients, one of whom might be having a stroke.
They don’t sleep. They often can’t shower. Older patients become confused, and confused patients fall. A study last year by Dr. Teodora Vasquez and colleagues, looking at about 200,000 admissions, found that older patients who boarded for more than 24 hours were more likely to develop delirium and stayed in the hospital longer, even after adjusting for how sick they were.
And while they wait, the waiting room fills. The man with chest pain sits in a plastic chair for three hours because the room he should be in is occupied by someone who should be upstairs.
It is not an ER problem
I want to be clear about where this comes from. Boarding is a hospital problem that shows up in the emergency department. It happens when inpatient beds are full, often because patients who are ready to leave can’t, since there is no nursing home bed, no home health aide, no rehab spot.
The fixes are known. Hospitals can discharge earlier in the day, staff weekend discharges like weekdays, and pay for transitional beds. Regulators can measure boarding time and publish it, hospital by hospital.
None of that is glamorous. All of it would help the 84-year-old in my hallway more than anything I can do for him at 3 a.m.
Julian Abernathy is an emergency physician in Albuquerque, N.M., and edits Second Opinion.