Emergency department boarding not only complicates hospital operations and hampers care quality, but it also places a significant financial burden on health systems, a recent study suggests.
Although average ED boarding time fell from 182 minutes in 2022 to 110 minutes in 2023, boarding remains a challenge for high-volume EDs. For EDs that treat more than 80,000 patients annually, boarding time was 178 minutes last year, according to federal data cited by the Emergency Department Benchmarking Association.
While many peer-reviewed studies have studied ED boardings' effects on care quality, patient safety and experience, fewer have delved into their financial ramifications.
To fill this gap, researchers at UMass Chan Medical School and UMass Memorial Health in Worcester, Mass., applied a time-driven, activity-based costing methodology to estimate care costs associated with boarding patients in the ED versus treating inpatients. The study assessed care for acute stroke patients admitted through UMass Memorial Medical Center's ED in a four-week period between January and February of 2022.
The results were notable: the daily cost of ED boarding was twice as high as daily inpatient costs, even before considering the opportunity cost of keeping an ED bed occupied.
"This study adds an additional piece of information related to boarding that wasn't available to hospital leaders previously in the literature and gives some insight, potentially, on what the financial implications are at their own individual sites," senior author Martin Reznek, MD, MBA, professor and executive vice chair for clinical operations and education in the department of emergency medicine at UMass Chan Medical School and UMass Memorial Health, told Becker's. "This was a single site study, but we have no reason to believe that it's not generalizable to other hospitals."
The research, published this spring in Annals of Emergency Medicine, was the first to use detailed observational data to examine the financial implications of ED boarding and compare those costs with inpatient care for matched patients, according to lead author Maureen Canellas, MD, MBA, assistant professor in the department of emergency medicine at UMass Chan Medical School and associate chief medical officer of UMass Memorial Medical Center in Worcester.
The financial findings add a new sense of urgency for health systems to address ongoing challenges of ED boarding.
Four takeaways from the study:
1. Daily ED boarding costs were nearly two times higher than daily inpatient costs for stroke patients, the study found. The daily total cost for medical/surgical boarding was $1,856, compared to $993 for medical/surgical inpatient care. Dr. Canellas attributed the higher cost of boardings to three key drivers: the overhead of using a more expensive ED bed, higher nurse staffing costs and higher physician costs due to redundant care.
2. This cost difference becomes even larger when there are more travel nurses working in the ED compared to inpatient units. When accounting for travel nurse costs — with travel nurses making up 35% of a hospital's ED nursing staff and 13% of inpatient unit staff at the time of the study — the daily total for medical/surgical boarding was $2,258 compared to $1,095 for medical/surgical inpatient care.
3. Cost differences between ICU care and boarding were smaller, though boarding was at least 5% more expensive, the study found. ICU boarding cost $2,267 daily, on average, compared to $2,165 for ICU inpatient care. With travel nurse costs included, these figures jumped to $2,843 for boarding and $2,423 for inpatient ICU treatment.
4. Outside of financial costs, staff anecdotally reported that patients in the ICU may have received more nurse care than those boarding in the ED, according to the study.
"It's not only more expensive for that inpatient to be boarding in the ED, but it is also less equitable care time by rote numbers," Dr. Canellas said.