Emergency department boarding: a descriptive analysis and measurement of impact on outcomes.

OBJECTIVES: Delays in transfer of admitted patients boarded in the emergency department (ED) to an inpatient bed is a major driver of ED overcrowding. We sought to identify explanatory factors behind ED boarding as well as the impact of boarding on total inpatient length of stay (IP LOS) and inpatient mortality. METHODS: We conducted a retrospective single-centre observational study during the period between January 1 and December 31, 2015 at a very high volume community hospital. All patients admitted from the ED to Medicine, Pediatrics, Surgery, and Critical Care were identified. The mean ED LOS and boarding time as well as patient-specific and institutional factors that were independently associated with prolonged ED LOS (≥24 hours) and prolonged boarding time (≥12 hours) were identified. Mean inpatient length of stay (IP LOS) and the odds of inpatient mortality were calculated for those patients with prolonged ED wait times. RESULTS: There were 13,872 unique admissions during the study period. Patients admitted to the Medicine service exhibited significantly higher ED wait times than other services. Within Medicine patients, there was a statistically significant greater odds of prolonged ED wait times for patients who were older, had a greater comorbidity burden, and required more specialized inpatient care. Medicine patients with prolonged boarding times also experienced a mean of 0.9 days longer IP LOS even after adjusting for confounders. CONCLUSION: Within our cohort, older, sicker patients and those patients requiring more resource-intensive inpatient care had the longest ED wait times. These prolonged wait times are associated with significantly increased IP LOS.

Six Change Ideas that Significantly Minimize Alternate Level of Care (ALC) Days in Acute Care Hospitals.

A significant issue affecting the healthcare system across Ontario is the number of patients admitted to hospitals that are then subsequently being designated alternate level of care (ALC). In 2016, 14.5% of Ontario in-patient beds were occupied by ALC-designated patients. Contributing to this phenomenon are ethical errors that can affect decision-making around discharge. Since 2012, William Osler Health System has redesigned their discharge process to eliminate ethical errors and align more fully with the Health Care Consent Act (HCCA) and the Public Hospitals Act (PHA). Through quality improvement processes including the use of scripting, education, checklists, mentoring and role clarity, Osler's ALC days are currently the lowest in the province of Ontario. The elimination of such errors also decreased patient confusion and improved the discharge experience.