The Effect of Emergency Department Boarding on Order Completion

We identify differences in the process of care for admitted patients who board in the emergency department (ED) compared with admitted patients who are transferred to an inpatient care area.

This is a retrospective study of a random sample of adult patients admitted through the ED at one urban teaching hospital. Patients who boarded in the ED for at least 6 hours after the decision to admit were matched to similar control patients. Data were collected by 2 trained medical students using a standardized data abstraction tool. All physician orders placed in the first 24 hours after admission orders were signed were identified. The medical record was searched for documentation of order completion. Each order was classified as being executed on time, delayed, or missed.

Of 848 patients screened for inclusion in the study, a total of 145 matched case-control pairs were included, making a total of 290 patients. A total of 9,260 distinct orders were identified. Use of a generalized estimating equation that controlled for correlation within subjects showed that orders were less likely to be completed on time for boarders than for controls (odds ratio [OR] 0.46; 95% confidence interval [CI] 0.38 to 0.55). Among boarders, orders were more likely to be either delayed (OR 1.84; 95% CI 1.46 to 2.30) or missed entirely (OR 2.58; 95% CI 1.94 to 3.42). Boarders missed a median of 11 orders during their first 24 hours of admission compared with 6 orders for control patients.

This study detected an important process difference between boarded patients compared with control patients, which could explain previously suggested outcome differences between these 2 groups. This provides additional support for efforts to move patients to inpatient care areas in a timely fashion rather than board in the ED.