Emergency Department Boarding Stories

"I work in two emergency departments. One is a 60 bed emergency department and the other is about 40 beds. Both have had very poor outcomes due to the issue of ED boarding. Unfortunately, everyone who works at both sites also has their own stories. All of which could have been prevented if there was available space or appropriate placement into an inpatient bed. One story is while our 40 bed ED was boarding a large number of patients up to several days awaiting an inpatient hospital bed with a waiting room of >30 people. We had someone in the lobby who was not being appropriately monitored and began having large bloody vomiting. Vitals were only available from when he initially presented to triage almost eight hours ago. He lost pulses in the waiting room in front of others including children. As the resuscitation began in the lobby, this posed high risk for other patients in the lobby as we began CPR while blood ejected from his mouth with every compression. 

This posed high risk for other patients in the lobby as we began CPR while blood ejected from his mouth with every compression.

It wasn't until he was in a proper room that we were able to obtain IV access and suction the blood. This was not only scarring for the others and hospital workers, but may have been avoided if our emergency department was decompressed and an appropriate history/exam/workup had been done by me or another physician much earlier in order to initiate treatments that have been shown to improve outcomes related to his presenting complaint and known risk factors. A similar situation of a cardiac arrest occurred in a patient complaining of chest pain at our 60 bed ED while the lobby was full of >50 people and we were boarding some people for up to three days pending inpatient bed placement or placement to an inpatient rehab or skilled nursing facility.

While boarding in the ED, we are responding to new ambulances as they arrive and often these boarding patients are not as well watched as they would be in the hospital. Due to lack of resources, I have had patients aspirate, develop DVTs, and decompensate on shift while they were boarding ultimately requiring ICU level care when they previously did not. These boarding patients require nursing and physician teams in the hospital since they need these resources that we cannot provide them during a busy ED shift. As an emergency department physician, I should not be responsible for their inpatient management as I am less qualified for this compared to the inpatient doctors.

Unfortunately, this feels like the new reality and the lives of these patients seem not to matter to hospital administration.

If this was any of my family members, I would be livid. Unfortunately, this feels like the new reality and the lives of these patients seem not to matter to hospital administration. We primarily need nurses to help fill the shortage of them on the inpatient wards to decompress the emergency department and ultimately improve outcomes. I envision a world where we can incentivize to retain nurses within the system and keep job satisfaction high. Travel nurses were never a solution and only worsened the issue, which was something many physicians predicted. Travel nurses required resources to teach them a new hospital system, new protocols, and costed the hospital a large amount of money only for them to leave to their next assignment once they finally became comfortable. Please help us find solutions for our patients. The solution is nurses that can staff the hospital floors and emergency departments. This is increase flow and ultimately lead to better outcomes for our patients."