How One Boarding Problem Can Create Multiple Patient and ECAT Failures

Boarding does more than extend an admitted patient’s ED stay. It consumes capacity required to keep other patients moving.

When patients remain in the emergency department (ED) waiting for an inpatient bed, the most obvious problem and metric we track is boarding. It is the canary in the coal mine for other impacts to patients and staff as it puts pressure on several areas at once.

For hospitals preparing for CMS’s Emergency Care Access and Timeliness (ECAT) measure, they may be seeing multiple ECAT failures stemming, at least in part, from the same capacity problem.

When those beds are not turning over for patients waiting to be seen, that can mean longer waits, more patients leaving without being seen (LWBS), and more visits extending past eight hours.

ECAT now highlights the impacts on patient care that were once hidden in silos.

Boarding Changes the Capacity of the ED

An ED may have the same number of physical beds from one day to the next, but that does not mean it has the same capacity to care for incoming patients.

Admitted patients waiting for beds still require nursing care, monitoring, medications, reassessment, and other resources. They also continue to occupy treatment spaces that would otherwise become available for incoming patients. As the number of boarders grows, the ED has less capacity to move patients out of the waiting room and into effective treatment spaces.

Boarding is not the only factor affecting ED capacity and flow. Arrival patterns, acuity, staffing, diagnostic turnaround times, and many other factors influence performance.

The Relationship Shows Up in the Data

A recent analysis of work at a regional hospital is shown in the chart below. While correlation does not equal causation, statistical analysis for this hospital showed a moderate correlation between patients leaving without being seen and boarding. This does not suggest that every patient who leaves without being seen does so because another patient is boarding. However, it does point to the need for deeper dives into the impacts felt by patients.

When LWBS rates rise, for example, leaders can look at what else was happening in the Emergency Department at the same time.

• How many patients were boarding and for how long?
• Which days of the week and hours of the day were most affected or outliers?
• Was patient care impacted by mismatched demand and capacity?
• What happened to waiting room volume and door-to-clinician times during those periods?

Under ECAT, leaders need to understand the patients behind the aggregate result and what was happening in the ED during encounters that did not meet a measure.

One Constraint Can Surface in Several ECAT Measures

Looking at each of the four ECAT measures separately could lead to four separate improvement efforts, even when several of the failures share the same underlying constraint.

This is where an ECAT score can become misleading if leaders look only at individual measures.

A hospital might see too many patients exceeding its boarding threshold. At the same time, it may have patients waiting too long to see a provider, an elevated LWBS rate, and too many encounters lasting eight hours or longer.

If prolonged boarding is repeatedly removing treatment spaces from circulation during periods when other measures deteriorate, improving backend patient flow may improve more than the boarding measure itself.

If LWBS remains elevated during periods when boarding is low, and treatment capacity is readily available, leaders may need to look to registration, triage, staffing, or another front-end process. That distinction is difficult to make from an aggregate score alone.

ECAT Requires Looking Beneath the Metric

Digging deeper into the metric beneath the surface is why we at d2i emphasize high-fidelity data that reflects actual clinical workflows rather than treating performance measures as standalone numbers. d2i’s Performance Insights for Emergency Medicine™ gives clinical and operational teams the context to investigate what is contributing to performance and act on what they find. For ECAT, that means moving beyond the numbers to the patients and staff behind them.

Improving ECAT performance requires involvement beyond the ED, and Performance Insights for Emergency Medicine™ provides credible data to hospital leaders showing when constraints affect patient flow and which patients are impacted.

Emergency medicine leaders may not be able to independently solve inpatient nursing shortages, discharge delays, bed assignment issues, environmental services constraints, and other factors that may keep admitted patients in the ED. And yet, having this level of insight provides hospital and ED leaders a much better starting point for ECAT improvement.