Quality and Safety Implications of Boarding Geriatric and High Acuity Patients in the Emergency Department: A Literature Review

Abstract Boarding of inpatients in the emergency department (ED) who have been determined to require admission but remain in the ED because of a lack of inpatient bed availability is a significant contributor to delayed ED throughput. In addition, boarding is associated with adverse patient outcomes, including increased mortality and escalation to a higher level of care. Failure to receive their prescribed level of care and delayed care may contribute to unfavorable outcomes that extend into hospitalization, even after they have been transferred to the appropriate level of care. Older adult patients may be especially vulnerable to delirium during boarding because of 24-hour stimuli and lack of routine. Patients with higher acuity are at higher risk of errors during boarding, and boarding is also associated with in-house mortality across all levels of care. Objective: The purpose of this narrative review was to review existing literature to determine a consensus of established best practices to mitigate the risks of boarding geriatric and high acuity patients. Methods: The PubMed database was searched using the following key terms: quality care, inpatient boarding, emergency department, nursing care, and access block. Results: Fourteen articles were reviewed, identifying quality and safety concerns, organizational imperatives, and potential solutions. Conclusion: The care of boarding patients poses unique challenges for hospitals, physicians, and nurses. Organizational priorities should include strategies to minimize boarding in the ED and interventions to improve the quality and consistency of care when boarding cannot be avoided. Discharge lounges, a popular alternative, fail to demonstrate a return on investment or improved throughput.