# Designing Care Processes to Reduce Boarding and Associated Harm

A Compounding Problem

As an emergency clinician or care provider, you have likely encountered the growing problem of boarding. Boarding occurs when patients remain in the emergency department (ED) while waiting for an inpatient bed. Driven by a number of contributing factors, it is a system-wide issue that increases ED crowding, strains capacity, and makes delivering high-quality care even more challenging.

Older adults are disproportionately affected, and the longer they remain in the ED, the more likely they are to experience negative health outcomes, including delirium and functional decline. What’s more, frail older adults who spend a night in the ED are more likely to have a longer hospital length of stay (LOS) and face increased risk of in-hospital mortality — all compounding the problem across the system.

Where Meaningful Change Begins

Minimizing the harmful effects of boarding begins with having care processes in place for older patients. While many hospitals are already making meaningful progress, consistently meeting all the best practices will only raise the overall standard of care — and make it more sustainable.

If you’re preparing to implement change in your hospital, it’s essential to understand the core building blocks of a care process that addresses boarding. This article provides an overview of the necessary steps, along with practical tips to help you put them into action.

As a starting point, it may be helpful to review the Geriatric Emergency Department guidelines and accreditation standards. They outline care practices for older adults who are boarding and closely align with the CMS Age-Friendly Hospital Measure.

Under Domain 3 of the CMS Age-Friendly Hospital Measure, there is a sub-domain focused on addressing ED length of stay (LOS) and boarding. It highlights that hospitals meeting the measure will have protocols to reduce the risk of ED delirium by shortening LOS, with a goal of transferring a targeted percentage of older patients out of the ED within 8 hours of arrival and/or 3 hours of the decision to admit. 

The Geriatric Emergency Department Accreditation (GEDA) guidelines list two care processes specific to boarding:

 F1: A care process to minimize ED boarding for geriatric patients, or sub-groups at particularly high risk of harm due to prolonged ED stay.

F2: A care process to optimize care of geriatric patients, or sub-groups at particularly high risk of harm, who are boarding in the ED for an extended period after the decision to admit.

Prioritizing Open Inpatient Beds

One way to minimize harm from ED boarding  is effectively prioritizing open inpatient beds for patients at greatest risk of harm from boarding.

Every hospital serves a unique population. Both the GEDA care processes and the CMS Age-Friendly Hospital Measure will require your hospital to develop criteria that help you assess which patients are most at risk of adverse outcomes from prolonged boarding. Below, we offer a few ways to begin thinking about at-risk patients. While your hospital will have its own challenges and factors to consider, the following examples may help guide your decisions.

Small Communities vs. Large Systems

Larger systems and hospitals will build their screening criteria into their electronic medical records (EMR) and include department training on a quality improvement process like this one. .  

For rural and small community hospitals, or less-resourced hospitals, a low-fidelity approach could be very effective. You may not need complex integration into the EMR because your ED staff may know most of the patients you’re seeing and be able to make clear recommendations of who has a higher risk from prolonged boarding. This process requires intentionality more than lots of IT integration.

Identifying At-Risk Patients

When trying to identify which patients are most at-risk it may be helpful to consider the following criteria:

Cognitive Impairment

We know that prolonged ED LOS is associated with the development of delirium, and those with underlying cognitive impairment are at a higher risk of developing delirium. Older adults, especially those with advanced age, are more likely to have underlying cognitive impairment, putting them at greater risk.

ED-Appropriate Screens for CI: 

Mini Cog 

6-Item Screener 

4AT 

Care Needs Cannot be Met in the ED 

Each ED has different capabilities. Can your emergency department initiate chemotherapy? Can it provide peritoneal dialysis? If not, your patient should be prioritized for transfer to the appropriate inpatient area. Consider also if your patient is coming from Long-Term Care. Do you know which procedures and services are available in the care facility that could be done after discharge, like the administration of IV antibiotics? Making a call ahead of a decision to admit may prevent prolonged boarding and faster transfer back to the care facility.

Physical Disability and Frailty

If your hospital is already routinely screening for frailty, consider using it as part of your criteria for vulnerable patients. Frail older adults and patients with physical disability have a harder time mobilizing in the ED environment, which puts them at risk of complications such as pressure ulcers, functional decline, delirium, and increased LOS.

Screens for Frailty:

FRAIL Scale 

Clinical Frailty Scale 

ISAR 

Electronic Frailty Score using the EMR: 

Age ≥80 

Chief complaint of fall (mobility) 

History of dementia documented in EMR (mentation) 

≥5 ED visits within last year (high healthcare utilization) 

≥10 home meds (medication)

Other Criteria to Identify Patient Vulnerability

It's possible your ED is already looking into other criteria for care processes that could also identify a vulnerable patient for prolonged ED boarding. Additional criteria that you could use in a care process include:

ESI 2 (Emergency Severity Index) 

This index is commonly used in emergency departments. It recognizes patients who are more critically ill and may be at greater risk of adverse outcomes from boarding. However, it is not specific to geriatrics. In fact, it tends to under-capture the severity of illness in older patients.  

In some Canadian hospitals, at the time of writing this article, a frailty assessment is included in the ESI score to ensure older adults’ risk is captured. 

Unstable vital signs (hypotension, tachycardia, hypoxia)  

Presence of delirium  

Presence of moderate to severe cognitive impairment  

Need for 1:1 sitter for any reason (medical, social, psychiatric, or falls risk).   

Age >85

Outcome Monitoring 

Monitoring outcomes of your care processes will be similar whether your focus is meeting the CMS Age-Friendly Hospital Measure or GEDA Accreditation criteria. As you design your care process, here are some practices to keep in mind:

Report on median boarding time in the ED and compare geriatric versus non-geriatric patients.  

Report on the percent of patients who board in the ED for greater than 4 hours, 8 hours, and 12 hours. Compare between geriatric versus non-geriatric patients.

Preventing Harm During ED Boarding

When a frail older adult who is at risk of harm from boarding has to wait for an inpatient bed in the emergency department, there are a number of interventions EDs can employ to minimize harm. Eliciting care goals, preventing delays, preventing functional decline and frequent CI screening are just some examples. What’s more, if we can improve care in the ED, we can reduce inpatient LOS which in turn helps open inpatient beds for other patients.

Optimizing Care for At-Risk Patients

Elicit Patient Care Goals 

If you know your patient will need to be admitted, and likely will have to board in the ED, it’s important to understand their care goals and what will matter most for comfort and function early on. Set realistic expectations for boarding and consider alternatives to hospital admission where appropriate. 

Avoid Delays in Care

Avoiding delays really means ensuring care progresses during the boarding period. This involves conducting a medication history and ordering any essential medications, as well as any anticipated diagnostic tests. Examples include:

Ordering anticipated diagnostic studies (echocardiogram, MRCPs, etc.) 

Arranging anticipated consults (PT/OT, Pharmacy, Social Work/Case Manager/Care Coordinator) 

Requesting medical specialty consults such as GI, Cardiology, Interventional Radiology

Requesting medication review

Enable Function 

Provide regular meals and assist with cutting food or feeding if necessary.

When conducting a PCA pilot program, we observed that one-quarter of patients in our ED needed help cutting their food, and 5% needed feeding assistance — so giving a tray is not always enough.

Ensure patients have water available (a cup or pitcher within reach of their bed or chair). 

Check that patients have appropriate sensory aids like hearing amplifiers and glasses, or provide them if they arrived without them. 

Provide cognitive engagement, especially during the day.  

Coordinate regular toileting rounds.

Support the bedside RN in carrying out rounds every 2 hours so that mobility, comfort, function, nutrition, toileting, and hydration needs are met. All of these are important interventions for preventing delirium.

Serial Assessments for At-Risk Older Adults

Older adults can become more vulnerable as time passes in the ED. Serial assessments for delirium, functional decline, vitals, etc. can help alert your team early if your patient is experiencing harm from boarding.

Enhance Patient (and caregiver) Comfort

Assess needs for patients with caregivers. Prioritize rooms that allow them both to wait comfortably.

Promote a sleep-wake cycle. 

For patients boarding at night: 

Dim lights. 

Provide a warm blanket.  

Provide a sleep-hygiene packet with earplugs and non-slip socks. 

Ensure alarms are silenced if possible to reduce ambient noise in the room. 

Arrange a private room, if possible. 

Provide pressure-reducing mattresses or hospital beds. 

Cohort in quieter areas of the ED.

Optimize Mobility

Optimizing mobility will prevent functional decline, and is just one non-pharmacological  intervention for delirium prevention. It can prevent complications like bed sores or falls in the ED and improve overall patient experience. Some actions your ED could take include: 

Providing a chair rather than requiring the patient to remain in bed (where appropriate) 

Ensuring adequate supply of mobility aids: walkers, canes, and 4-point canes 

Arranging a PT/OT consult

Completing mobility rounds on a regular basis.

Mobility Rounds

Rounding hourly to ensure patients are mobilized is ideal during the daytime. Promoting the sleep-wake cycle is important for at-risk patients, so don’t disrupt sleeping patients at night.

These rounds can include other assessments that will be performed later in the inpatient setting. Emulate what the inpatient unit provides to support better outcomes — and continuity of care.

Make Best Practices the New Standard

By adopting vetted care practices in your facility, older adults are less likely to experience negative outcomes associated with prolonged ED LOS. Doing so also helps ensure your team is better prepared to meet the CMS Age-Friendly Hospital Measure and the Geriatric Emergency Department Accreditation standards.