Boarding Solutions
Increase Profits by Ending Gridlock
[Physician Name]
[Date of Meeting]
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Introduction to Physicians

The Virginia College of Emergency Physicians developed this document to help
members talk with their administrators about addressing boarding.

You may customize this document for your hospital’s unique situation.

We included “placeholders” indicated with brackets throughout the document.
For example, the cover slide has two placeholders that you should customize:
 [Physician Name]
 [Date of Meeting]

We also added speaker’s notes for some slides in the “Notes View” to help
guide the conversation.

Visit www.vacep.org/boardingtoolkit for more information on boarding,
including in-depth presentations and documents you can use to customize this
document.
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Contents
1.
Why Address Boarding

Impact on patients

Impact on bottom line

State guidance
2.
Internal Scan: Our Situation
3.
External Scan: What’s Working in Virginia

Bridge orders

Admission units

Rapid Intervention Treatment Zones and Results Waiting Areas

Special situations: mental health patients
4.
Recommendations
5.
Resources
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Why Address Boarding
1.
Addressing boarding reduces crowding

ED crowding often occurs because no inpatient beds are available in the
hospital, not because we have patients with non-urgent medical
conditions

“Boarding” means holding patients who have been admitted to the
hospital in the ED, keeping them on gurneys or chairs in hallways and
waiting areas
2.
Boarding has a negative effect on patient safety, comfort and satisfaction
3.
Boarding ties up emergency department resources resulting in fewer
physicians and staff to care for patients and, ultimately, less revenue
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Patient Satisfaction
Source: Press Ganey
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Quality & Safety
Source: Press Ganey
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2010 VDH Boarding Guidelines
The Virginia College of Emergency Physicians helped design state guidelines on
boarding with an eye toward making emergency department patients safer by:

Quickly moving patients to inpatient floors

Avoiding ambulance diversion

Freeing up resources for patients who are in critical need of emergency care
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Internal Scan
Note to members: adjust the table below to include the data that will best illustrate the
severity of boarding at your hospital.
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What We Have Done in the ED
Note to physicians: insert examples of changes you have made inside the ED
to address the problem.
Physician examples here

[One]

[Two]

[Three]
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Collaboration is Vital
“Emergency department crowding is an institutional
problem that goes well beyond the emergency
department.
Only when all stakeholders agree that the problem is
systemic and hospital-wide can solutions be
implemented that will improve patient flow from
triage to discharge and protect everyone’s access to
emergency care.”
2008 Task Force Report on Board
American College of Emergency Physicians
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External Scan:
What’s Working in Virginia
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Solutions for Success

Bridge orders

Admission units

Rapid Intervention Treatment Zones and Results Waiting Areas

Special situations: mental health patients
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Bridge Orders
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Bridge Orders: Challenge
HCA Henrico Doctors Hospital, Richmond, VA

Hospitalists visited stabilized patients in the ED before admitting them to the
hospital, which meant patients often had long waits for inpatient beds.

Meanwhile, fewer new emergency department patients could be seen because
stable patients were using ED beds while waiting for a hospitalist to admit
them.
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Bridge Orders: Solution

Now ED physicians call the hospitalist to discuss the patient’s status, level of
care, etc.

If the hospitalist and the ED physician agree that the patient can be sent
upstairs, the patient goes upstairs to a room and is admitted by the hospitalists
on the appropriate floor.

The ED physicians also complete a one-page bridge order outlining vitals, diet,
etc.

Goal: after phone call to hospitalist, patient goes to appropriate floor within
one hour.
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Bridge Orders: Benefits

Minimal cost

Increased patient safety, comfort, satisfaction

Decreased patient wait times

Increased revenue
172.8
69.3
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Bridge Orders: Steps for Implementation

ED physicians, hospitalists and administrators meet to discuss.

Set up a cross-functional team to implement.

Develop a hand-off tool to ensure information exchange is thorough for
patient.

Establish measures.

Once process is established, hold kick-off dinner to brief all parties on process.

Start during a slow time (e.g., a summer Tuesday).
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Bridge Orders: Considerations

Trust across teams is critical.

Patients that are typically good candidates for a bridge order include those
with pneumonia, pancreatitis, etc.

Patients should have stable vital signs.

This works well in a facility where hospitalists admit the majority of patients.

Avoid bridge orders when patients are unstable or if staff are debating about
whether a patient meets the criteria for bridge orders.

Pick one or two measures to focus on initially.
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Admission Units
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Admission Units: Challenge
Lynchburg General Hospital, Lynchburg, VA
 Staff recognized an opportunity to increase the efficiency of moving patients
from the ED Bay to the inpatient unit.
 Many floor nurses anticipated long, dedicated periods of time for admission and
therefore would wait until that specific period of time passed before they would
report the bed was 'ready’.
 Thus, the patient would remain in the ED Bay longer than necessary, clogging the
system.
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Admission Units: Solution

We develop the Admission Unit – a unit dedicated solely to the admissions
process.

Admission Unit nurses perform admissions duties quickly and efficiently, since
their role is focused on admissions. They handle all logistics, checklists and
initial orders so the floor nurses are no longer responsible for these tasks.

In short, the Admission Unit nurses “pull” the admitted patients from the ED,
then “push” them to the floor.
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Admission Units: Benefits

The Admission Unit improves flow in the emergency department. ED LOS is
decreased significantly and the patient vacates the ED bay as soon as the
doctor decides admission is warranted.

Admission Unit staffers process admissions efficiently, since their it primary
responsibility.

The Admission Unit enhances patient safety.

Admission Unit staffers take pride in their role.
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Admission Units: Steps for Implementation

Find a location for the admission unit.

Learn from others – we visited two hospitals to see their processes and
tailored them for our needs.

Determine goals for the admission unit (e.g., time goals, etc.).

Open the Admissions Unit with limited hours. Initially, we opened 12 hours/7
days, but later opened 24/7.

Add staff as needed. For example, we added a medical records nurse who is
solely responsible for obtaining accurate medical records. We also added a
floating nurse who can capture admission histories.
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Admission Units: Considerations

Location can be a challenge – think carefully about where to put the unit.

Dedicate a specific manager to the unit’s success.

Strict criteria are important when deciding whether to send patients to the
admissions unit; criteria may vary by hospital.
Sample Inclusion Criteria
 Medical/surgical patients
 OB patients (medical
reasons)
 Telemetry patients
 Neurologic Intermediate
Care Unit
Sample Exclusion Criteria
 Pediatrics
 ICU patients
 Seizure patients
 Titratable drips
 Mother/baby patients
 Mental health
 23-hour observation patients
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Rapid Intervention Treatment Zones
and Results Waiting Area
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RITZ and Results Waiting Area: Challenge
Sentara Potomac Hospital, Woodbridge, Virginia
 High incidence of ED boarding (hours and number of patients) and High LWOT
 No metrics
 Poor customer service scores
 Previous attempts focused on front end
 Needed to improve performance as new owners implemented key metrics
including:

The agreed upon metric in which the door to discharge time for

level 2s and 3s is < 180 minutes is met 39% of the time

levels 4s and 5s is <75 minutes is met 25% of the time

Percentage of patients to triage < 15 min is met 95% of the time
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RITZ and Results Waiting Area: Solution

The staff created a “Rapid Intervention Treatment Zone.” They also created a
“results waiting area” for patients who can stay vertical. This allows another
patient to be seen in the bed.
Zone
Staffing
Patients
RITZ 2
Mid-level providers (PAs, Nurse
Practitioners)
Level (Some level 3s,
mostly level 4s and 5s)
RITZ 1
Physicians
Level 3 (vertical)
Major Care
Physicians
Level 1, 2 and 3
(horizontal)
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Name of Initiative: Benefits

Minimal ED boarding

Improvements involve front, middle and back end

Clearly defined metrics

Gains in customer service scores
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RITZ and Results Waiting Area: Steps for
Implementation

Use the right tool for the right job. Look at the resources you have:

Human resources / staffing

Physical space

Determine the best way to allocate the right people for the right jobs.

Determine whether you have space for a results waiting area.

Develop a plan in collaboration with administrators, nursing and support
services.

Rapid Cycle Test and Refine.
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RITZ and Results Waiting Area: Considerations

As you evaluate your situation, look for ways to keep horizontal patients
horizontal and vertical patients vertical. In other words, if your patients don’t
need beds, don’t leave them in beds (results waiting area helps with this).

Focus on metrics and share the data. Transparency is critical for improvement.

Celebrate successes and learn from failures.

Share with and update administration and medical staff.
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Special Situations:
Mental Health Patients
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Mental Health Patients: Challenge
Carilion Clinic Roanoke Memorial Hospital, Roanoke
Excessive length of stay for mental health patients and boarding of mental health
admissions in the ED.
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20
Mental Health Patients:
Days per Month where
Avg ED Stay >800 minutes
Days
15
10
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12/2011
08/2011
02/2011
12/2010
10/2010
08/2010
06/2010
04/2010
02/2010
12/2009
10/2009
08/2009
06/2009
0
03/2009
5
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Mental Health Patients: Solution

Improve intake:

All mental health patients = Level 1 triage

Standardized patient intake

Created of dedicated ED Mental Health Unit

Improve throughput and care in the ED:

Dedicated ED Psych Nursing Staff + 1 fte RN, 1 fte ED psych unit med tech

Psych RN coordinators (Connect Team)

Parallel evaluations (med clearance and Connect Team)

ED Physician rounder on boarders (2hrs/day)

Improve disposition and placement:

“One Call” for all Mental Health Patients

Expanded weekend bed capacity

1-to-1 communication with ED physician and psychiatric team

County/City Mental Health Coordination with Connect Team

Automatic Psychiatry Consult for ED >24 hrs

Direct Facility Protocol Placement for Unique Patients
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Mental Health Patients: Benefits
25
Mental Health Patients Days/Month
Average ED Stay >800 minutes
15
10
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12/2011
08/2011
02/2011
12/2010
10/2010
08/2010
06/2010
04/2010
02/2010
12/2009
10/2009
08/2009
0
06/2009
5
03/2009
Days
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Mental Health Patients: Benefits
Mental Health Patients ED LOS in Minutes
900.0
800.0
700.0
600.0
500.0
400.0
300.0
03/2011
12/2010
09/2010
06/2010
03/2010
12/2009
09/2009
06/2009
03/2009
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Mental Health Patients: Steps for Implementation

Quantify the problem and map the process.

Improve care and maximize efficiency within the ED first.

Engage and collaborate across three key areas:

Law enforcement

City and county services

Inpatient and outpatient psychiatry

Expand resources and eliminate redundancy

Training, staffing, bed availability
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Mental Health Patients: Considerations

Expand the narrative: make it a community issue and not an ED issue.

Flow diagrams are critical to keeping everyone on the same page.

Variations in practice must be eliminated.

Relatively small upfront expenditures can have dramatic effects in LOS.
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Recommendations
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Opportunities
Note to physicians: insert examples of changes that you want to make in
collaboration with people outside the hospital.
Physician examples here
 One
 Two
 Three
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Resources
Dr. Tamera Barnes
Henrico Doctors Hospital
804-379-0444
804-432-0416
tcbarnes1@verizon.net
Dr. Chris Thomson
Lynchburg General Hospital
434-200-6858
434-401-7827
chris.thomson@centrahealth.com
Dr. Luis Eljaiek
Sentara Potomac Hospital
703-670-1283
703-670-1782
LFELJAIE@sentara.com
The Virginia College of
Emergency Physicians
757-220-4911
gwen@vacep.org
Dr. Damon Kuehl
Carilion Clinic Department of
Emergency Medicine
540-597-9153
drkuehl@carilionclinic.org
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