Boarding of Critically Ill Patients in the Emergency Department

Abstract

Objectives: Emergency department boarding is the practice of caring for admitted patients in the emergency department after hospital admission, and boarding has been a growing problem in the United States. Boarding of the critically ill has achieved specific attention because of its association with poor clinical outcomes. Accordingly, the Society of Critical Care Medicine and the American College of Emergency Physicians convened a Task Force to understand the implications of emergency department boarding of the critically ill. The objective of this article is to review the U.S. literature on (1) the frequency of emergency department boarding among the critically ill, (2) the outcomes associated with critical care patient boarding, and (3) local strategies developed to mitigate the impact of emergency department critical care boarding on patient outcomes.

Data sources and study selection: Review article.

Data extraction and data synthesis: Emergency department-based boarding of the critically ill patient is common, but no nationally representative frequency estimates has been reported. Boarding literature is limited by variation in the definitions used for boarding and variation in the facilities studied (boarding ranges from 2% to 88% of ICU admissions). Prolonged boarding in the emergency department has been associated with longer duration of mechanical ventilation, longer ICU and hospital length of stay, and higher mortality. Health systems have developed multiple mitigation strategies to address emergency department boarding of critically ill patients, including emergency department-based interventions, hospital-based interventions, and emergency department-based resuscitation care units.

Conclusions: Emergency department boarding of critically ill patients was common and was associated with worse clinical outcomes. Health systems have generated a number of strategies to mitigate these effects. A definition for emergency department boarding is proposed. Future work should establish formal criteria for analysis and benchmarking of emergency department-based boarding overall, with subsequent efforts focused on developing and reporting innovative strategies that improve clinical outcomes of critically ill patients boarded in the emergency department.

Figure 1.

Literature search strategy for defining the frequency of emergency department critically ill patient boarding. A MEDLINE search was conducted with the assistance of a medical librarian (Heather Healy) using the following search terms: (((((“emergency service, hospital”[MeSH Terms] OR emergency[tw]))) AND ((“crowding”[MeSH Terms] OR boarding[tw] OR crowding[tw] OR overcrowding[tw] OR patient throughput[tw] OR patient flow[tw]))) AND ((“ICUs”[MeSH Terms] OR ICUs[tw] OR ICU[tw] OR ICU[tw] OR ICUs[tw] OR “critical illness”[MeSH Terms] OR critical illness[tw] OR critically ill[tw] OR critical patient[tw] OR critical patients[tw]))).

Figure 2.

Subgroup delineation for potential mitigation strategies to combat resuscitation care unit (RCU) boarding. ED = emergency department.