Improving Emergency Department Boarding Time: Balancing Efficiency and Safety

Emergency department (ED) crowding and prolonged boarding times negatively impact care. Our objective was to decrease the average ED boarding time for patients admitted from the ED to any inpatient (IP) acute care unit at our main campus by 35% over 24 months.

Our multidisciplinary team used the Model for Improvement to identify inefficiencies within the existing admission process and created a key driver diagram to guide intervention design. Serial Plan-Do-Study-Act cycles tested and refined interventions initially piloted on one high-volume IP unit before implementation across the institution. Interventions focused on creating shared knowledge of the admission process, optimizing IP room preparation, improving communication between process stakeholders, and streamlining the admission process. We used statistical process control charts to measure the impact of our interventions over time. Our outcome measure was ED boarding time. Very rapid transfer rate, or patients transferred to an intensive care unit within 3 hours of admission, and ED length of stay (LOS) were balancing measures. Our left without being seen (LWBS) rate served as a measure of care access.

Our average ED boarding time decreased by 40% from 169 to 102 minutes, accompanied by a decrease in ED LOS and LWBS rate. There was no change in our very rapid transfer rate.

Engaged institutional and site of care leadership was integral to our project success. By understanding our system, creating clear expectations for process timelines, and streamlining communication, we were able to meaningfully improve transitions of care.