The Effect of Hospital Boarding on Emergency Medicine Residency Productivity

Abstract

Introduction: Emergency department boarding has escalated to a crisis, impacting patient care, hospital finances, and physician burnout, and contributing to error. No prior studies have examined the effects of boarding hours on resident productivity. If boarding reduces productivity, it may have negative educational impacts. We investigated the effect of boarding on resident productivity as measured by patients per hour and hypothesized that increased boarding leads to decreased productivity.

Methods: This was a retrospective study at a quaternary, urban, academic Level I trauma center from 2017-2021 with a three-year emergency medicine residency of 10-12 residents per year and annual volumes of 80,000-101,000. Boarding was defined as the time between an admission order and the patient leaving the ED. We created a multivariable mixed model with fixed covariates for year, month, day of week, resident experience, shift duration, total daily ED patients, and with residents as repeated measures. The effect of boarding was estimated after covarying out all other factors.

Results: All variables included in the model were significantly associated with changes in productivity. Resident experience has the largest effect such that for each month of residency experience, a resident adds 0.012 patients per hour (95% confidence interval [CI] 0.010-0.014). Isolating the effect of boarding demonstrated that for every additional 100 hours of boarding, a resident's productivity decreased by 0.022 patients per hour (95% CI 0.016-0.028). In the study, the median daily boarding was 261 hours; if this were eliminated (assuming a resident completes 100 10-hour shifts annually), a resident could be expected to see 56.9 more patients per year (95% CI 40.7-73.1).

Conclusion: Hospital boarding significantly reduces resident productivity as measured by patients per hour. Further studies are warranted to determine the educational impact.

Figure 1.

Boarding across study years. Line set at median boarding hours across the entire study period (261 hours/day). Each box plot represents a month (line = median, box = 25^th to 75^th quartile, whiskers = typical extremes, circles = outliers). Note: April 2020–July 2020 hours are not available as they correspond to the beginning of the COVID-19 pandemic.

Figure 2.

Multiple regression results predicting new patients per hour per resident for each variable. All values (year, month, day of week, EM resident months, total patients, shift duration) in model held at reference standards with adjustments to boarding (last panel of each graph). Expected patients per hour in each scenario is indicated by the red number in the Y axis with 95% confidence intervals in blue. As boarded hours change (last panel of each graph) so do patients per hour (red number to left of each graph) in each of the three scenarios (A: Median boarding of 261 hours. B: Reducing boarding by 100 hours. C: Eliminating boarding hours.)