Experts measure two types of patients who leave the emergency department without being seen. Leave without being seen (LWBS) patients have completed administrative paperwork or were seen by a triage nurse. Leave against medical advice (LAMA) patients leave either during the diagnostic or treatment period.
Both situations tend to occur when patients experience frustratingly long waits in the ED/ER. Patients who leave without being seen or against medical advice can face a much higher risk of poor outcomes.
With increasing boarding times becoming a worse problem in recent years, health organizations need to ensure they are doing everything possible to reduce this duration. Let’s examine the increasing problem of ER/ED boarding times and how to take corrective action.
Emergency Department Boarding is an Increasing Problem
Boarding time is the amount of time patients spend in the emergency department. It can generally be defined as the median time between the admitting decision time and the departure time for admitted patients. This includes being transferred to another department with inpatient beds.
Unfortunately, ED boarding time has been increasing in recent years. It has become even worse as a result of the COVID-19 pandemic.
Another problem is that various time stamps are used to begin the definition. These could include:
- Placing a bed order (ED clerk)
- Contacting the bed coordinator (ED charge nurse)
- Writing an admission order (Admitting physician)
- Changing status to admitted in the information system (emergency physician)
The lack of cohesiveness in definition means it is difficult to quantify differences between facilities and to chart progress over time. However, comparing boarding time based on size and type of ED is very important, as these factors can also cause differences.
Delays Cause Mistakes or Worse
Lower time in the ED corresponds to improved treatment access and improved quality of care. However, increased boarding time can lead to poor outcomes.
If boarding times are not improved, EDs can deal with crowded conditions, a lack of care areas for patients, and insufficient staff. In turn, this can lead to a cascade of more severe problems, including:
- Prolonged wait times
- Increased patient suffering
- Poor patient outcomes, including death
- Ambulance diversion
- Unpleasant environments
Emergency departments that become overwhelmed and have reduced capacity cannot respond to disasters and emergencies in the community. It can also affect staff, as dissatisfaction, frustration, and turnover are more common in EDs with longer boarding times.
Lack of Bandwidth Drives Patients to Leave without Care
The Joint Commission recommends that boarding times be no more than four hours. Unfortunately, researchers found that if an ED is at 85% capacity or greater, the median boarding time soars to 6.58 hours.
When patients are forced to wait long hours to be seen or treated, they may be stuck in the waiting room or the ED hallway. Some become frustrated and leave.
While the problem centers on the emergency department, it is not necessarily the root cause. It often indicates overwhelmed staff and resources and deeper issues within the system.
The national benchmark is 1% of patients leaving without being seen. The average for LAMA patients ranges from 0.5-3%. Meanwhile, the average for LWBS patients has increased from 1.1% to 2.1% between January 2017 and December 2021. The worst hospitals in the 95th percentile have rates up to 10%. Previously, this group had leave rates of 4.3% in January 2017.
How to Improve Patient Boarding Time in the ER & ED
Improving patient boarding time in the ER/ED requires attacking the problem from a few angles. We must improve admission flow, establish a usable care hierarchy, and leverage technology and software.
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Better Admission Flow
Better admission flow happens when preliminary work occurs outside of the ED. This can be done in a few ways. First, the rapid flow of inpatients can be linked to nursing incentives, such as financial incentives, recognition, or communication enhancement.
In addition, patients can be triaged, “worked up.” and already have critical therapies started when the doctor sees them. This allows the physician to assess the patient and get treatment started more promptly.
Establishing Better Care Hierarchy
In some hospitals, the ED has essentially become an inpatient unit, which takes up a lot of room, thus, preventing the staff from treating other patients. To rectify this, a better care hierarchy that treats the ED as an emergency department needs to be implemented. EDs should assess, stabilize, and possibly resuscitate the patients. After stabilization, patients should be transferred to a more appropriate department. This frees up beds, staff, and other resources, therefore reducing wait times.
Leveraging Technology & Software
Your organization can also leverage technology and software that makes patient intake and monitoring easier. For example, you can encourage patients to use technology that helps route them to the correct level of care. This could prevent patients from coming to the ED that don’t need to be there and encourage patients that may otherwise put off care to proceed with seeking the care they need.
In addition, technology such as Clearstep can help reduce administrative burdens. This frees up time for staff to focus on patients and reduces wait time due to unnecessary tasks.
The Importance of Proper Patient Routing
Certain types of patients need different levels or types of care. For example, only some emergency rooms can adequately treat pediatric patients. Though one out of five children seeks care in an ED each year, only 15% of residency training time in EDs is focused on pediatrics.
Another common example of patients that need to be rerouted is those in labor. While many arrive at an emergency department, they are eventually routed to a labor and delivery unit.
Since severe staffing shortages are impacting EDs around the nation, it’s critical that patients are seen by providers that can actually help them. Doing so maximizes resources and ensures patients are quickly provided with the care they need.
One way to do this is to get a head start on patient routing before they leave their home. When using Clearstep, patients can check their symptoms using an AI chatbot. This technology can provide virtual triage that will direct them to the necessary care level. This gets patients who need emergency treatment to the ER and those that don’t to other units without clogging up additional resources.
Clearstep can also assist in monitoring patient symptoms after discharge. This helps decide whether a patient needs additional care, should be readmitted, or can continue with their care plan as symptoms improve.
Improve Your Patient Routing with Clearstep
Correctly managing resources and staff can make it easier to ensure patients can be seen quickly when they arrive in the emergency department. As a provider, it’s important to develop a better admission flow and care hierarchy that prevents patients from leaving the ED without being seen.
Leveraging technology like Clearstep can ensure patients get the correct level of care and that you can continue to monitor them as needed. By implementing AI chatbots, you can virtually triage patients while increasing touch points that provide a better quality of care.
Overall, Clearstep can ensure you provide timely, high-quality routing and care to every patient who comes through your emergency department.
Want to try Clearstep and see if it’s right for your organization? Schedule a demo today!