Good morning. So I'm going to talk about boarding and right now, you know, it's it's gotten a tremendous amount of press the whole idea that there's boarding and it's likely one of the greatest threats to health care after the pandemic. However, the reality is, is that we've actually understood that emergency departments and hospitals have been increasingly more crowded and that boarding was an impending threat to the health care system for a very long time. And so this is data from several years back where we knew about five years ago that there was about one hundred and thirty million patients presenting to emergency departments every year. And this represented a 30 percent increase from 2006. The average admission rate across the country is anywhere between twenty five and thirty three percent out of the emergency department. And of those admissions, we've noticed an increasing trend of critical care admissions from ICUs. I'm sorry, from emergency departments to ICUs over the decade of 2000, 2000 to 2009. And in the past decade, we've recognized that that that trend has increased as well. And so if we looked at the top 10 diagnoses that are responsible for critical care admissions from the emergency department, and this is this is part of a systematic review that was performed several years ago, there was an 80 percent increase in patients presenting to the emergency department that required an ICU admission between 2006 and 2014. So what is the outcome of crowding and what is what is crowding and what is boarding? Boarding is the state of remaining in the emergency department when a bed and resources are not yet available in the hospital in order to manage the patient. And so those patients remain in areas that were not necessarily designed to provide that care primarily. And so in this case, we're talking about the emergency department pre covid. We knew that boarding in hospitals across the country ranged anywhere between a median of a one to eight hours. And the prevalence in the literature was anywhere from two to eighty seven percent in most institutions across the country. Factors leading up to boarding included lack of capacity of inpatient beds, increased census in US emergency departments and a rising acuity in the patient population. The outcomes of boarding a critically ill patients in the emergency department include delays in care and critical and critical interventions, increase in ventilator days, increase in length of stay. And there are poor outcomes in terms of mortality related to boarding in the emergency department. This one study that specifically looked at patients that were admitted and consulted in the emergency department, but then boarded before being assigned to bed, identified that E.D. boarding was actually associated with an increased probability of not only persistent organ dysfunction, but also death. So then this happens, right? So I'm talking about data pre pre covid. So covid happens and now we have a covid effect. So an overlapping, an overlapping complexity on the issue of boarding that was preexisting. OK, so this is data that comes from thirty five academic medical institutions across the nation. And you can see the trends in terms of registrations across the nation. And you'll see that there's a drop in E.D. visits right around the period of covid. However, this we got we there was a recovery over several months to a year after that. And a year out from covid, those registrations or those number of visits into the emergency department had still not recovered to the pre covid levels. We noticed that discharges visits fell in the emergency department by forty six percent across the nation. However, over time, we noticed that the discharges from emergency departments started to recover, but they didn't quite recover. And so there was an increase in the admission rate from the emergency department into the hospital. Hospitalizations also fell initially after covid, but then they started to recover, too. And currently we've noted that hospitalizations to hospitalizations from emergency departments have actually exceeded pre covid levels. So what is the impact? Or at least let's talk about the acuity. The other thing that we noticed during this period of time was during covid, the acuity or the case misindex of our patients presenting to hospitals increased and peaked and right after covid. But then it never quite came back to the acuity of illness that we were seeing pre covid. So ostensibly patients that are presenting to emergency departments and hospitals today are actually sicker than they were just two years ago. So why do we think this is? There's a lot of hypotheses that are flying around, including the fact that we have an aging population and a higher complexity of patients that are presenting to our hospital systems. But in a period of two years to have the acuity and case mix index of our patient population increase so substantially, it's probably related to covid. Right. And so there's paper out of Nature Medicine that demonstrates that weeks to months and even years beyond having an acute phase covid infection. That there are there's evidence of frailty and events, cardiovascular, neurovascular, renal events that modify health such as such that we're seeing an increased rate of hospitalizations. Secondary, not necessarily secondary to acute covid, but as a consequence of what's a post post acute or chronic post covid state. So let's take a look at what's happening to hospitals now. So after covid, I mentioned that the hospitalizations have increased and the acuity has increased. But gradually what we found is despite covid having us recover from covid, we are now seeing increasing boarding patients in the Department of Emergency Medicine across the country. And so you can see here that our boarding numbers right now exceed any numbers that we were seeing before covid. And it has very little to do with a covid surge itself. Hospital occupancies are also going up, and so you can see here that as hospital occupancies go up, the boarding times have also increased in emergency departments and across the country, most academic institutions have an occupancy that's greater than 90 percent. And why is that important in this paper that was published just last year in New England Journal? What they identified is that most hospitals should be functioning at around 85 percent census. As you start increasing your your census, you have increasing borders in the emergency department and it becomes unsafe. I've just said that about 90 percent of most hospitals are at 90 percent capacity. So you can see that most institutions have an emergency department where they're not only borders, but it's a generally unsafe space for for patients and patients are waiting. So here's some data for locally from my institution. What we've looked at is data over the past three to four years. Our emergency department and surgical volumes have gone up, but are specifically our emergency department volumes have gone up by 20 percent over the past four years. Inpatient volumes have also gone up by 17 percent. And notice that our length of stay has also creeped up as well as the case mix index. So we think that the function of that length of stay is actually a function of our case mix index. Our patients are sicker and so they're staying in the institution longer, occupying those beds that we would otherwise be utilizing for acute patients coming out of the emergency department into the hospital. And the other piece that's connected to this is that as patients stay longer in hospitals, fewer people are getting discharged. So a 9 percent reduction in discharges in our hospital over several years. In the emergency department specifically, boarding hours have increased as a consequence of not having any capacity in the hospital. We've noticed that the length of stay in the emergency department has also increased. So those critically ill patients that used to wait anywhere between three to four hours for their beds are now waiting eight to 12 hours for those beds. And those wait times are actually encroaching on resources in the department such that patients that are lower acuity aren't getting access into emergency departments. This is leading to also diversion across the hospital such that patients that are critically ill at other institutions can't be transferred into our institution. But then we also have the inability in the emergency department to bring in emergent patients as a consequence of the diversion. So we have longer length of stays in the emergency department for ICU patients, longer wait times, increased diversion and delays for critically ill patients that are not necessarily that are either in our emergency department or waiting for transfer from outside hospitals. And patients are basically being seen and cared for in environments that weren't designed to deliver that care. So what are some proposed solutions? So we look at this from a standpoint of ameliorating the input versus the output and then the throughput. So a couple of things that we can think about and that we have actually deployed in our local institution is telemedicine and tele ICU. So in this particular, so this is Dr. Stigler. He's at our institution and they've established a tele ICU center whereby they actually provide tele monitoring to patients across the state of Alabama. And this has actually reduced the proportion of critically ill patients that have to be transferred centrally to our institution and allows them to stay in place while still being monitored and being provided care by an intensivist. Currently, they have been at the height of this program. They were able to actually cover a thousand beds, a thousand critically critical care beds across the state and actually outside the state to ensure that those resources were being provided to patients that were essentially in other hospitals without the resources, without the requisite resources, including intensivists. Another way to deploy telemedicine is actually deploying tele ICU into the emergency department. So in this one study, they looked at actually deploying a telemedicine to the emergency department to see whether or not it would actually have an impact on the patient's outcomes. And when they deploy this in the E.D. while the patients were boarding, they found that there were statistically lower odds of mortality ventilator days and hospital length of stay. So at UAB, we actually piloted a similar program and placed tele ICU monitors in our department and demonstrated that it was feasible and actually helpful because it actually offloaded a lot of the resources that would otherwise have been placed on physicians to do the physicians as well as the nurses that had to reassess these patients over time. And we're looking at piloting these in freestanding emergency departments where patients might be waiting or boarding for to be transferred into hospitals that are critically ill. So output, we need to make sure that we're coming up with a way to get patients out of the hospital and this is going to require discharge efficiency. It is extremely frustrating to know that you're in the ICU and have finally gotten a patient who can be downgraded to a step down or floor bed, except that that bed's not available. And so you can't pull a patient that's critically ill out of the emergency department or even transfer a patient from another hospital because your bed is occupied. And so looking at operations throughout your hospital and how to identify capacity for those downgraded patients is a strategy. So one of the strategies that we've deployed at our institution is creating a discharge lounge. And this has been done in a lot of institutions. But think about airport lounges. Essentially, you've identified patients that can be discharged and you can either let them stay in their bed until five or six o'clock at night when their families come to pick them up. Or you can move them to a discharge lounge, provide them with a meal, make sure that there's nursing care available, and free up that bed that can then be used to downgrade, for instance, a patient from another unit or to bring in a patient from the emergency department. The other thing is simply working with your operations teams to create different targets for discharge. Discharge at noon or one, maybe move that target to earlier in the morning and change the culture such that patients are moving out of the institution as early as possible. Other strategies for improving output is in the ICU, simply ensuring that when you identify patients that are at risk for experiencing a death in the hospital, that early palliative care is engaged very early on. Partnering with your palliative care teams, engaging in those discussions, and transitioning patients to their homes or to a hospice facility outside of the institution where they can provide a lot of this aggressive bedside care can actually help to free up capacity in your ICU. So at my former institution, the University of Florida, we had a partnership with a hospice where we did just that, and we identified ICU patients who we understood were not going to survive their stay. If families were interested, we could actually transition that patient to a freestanding hospice unit where they had a private room, monitors, medication, nurses, and families could be with those patients, and we would open up that ICU bed. Another strategy for improving output is hospital at home. Many of you may be at institutions that have already started deploying this, but essentially this is an opportunity to take patients that are not critically ill and transport them to their homes and use their home space as an alternative care space that's outside of the hospital itself. Finally, throughput. I'll just end with this one slide, and I'll tell you that at the height of the pandemic, all of the nurses in our emergency department walked out, and they striked. They were not going to go back in there because the conditions were really difficult. And of course, there were travelers, and compensation was not exactly what they wanted it to be. And we're seeing this across the nation. We saw a strike in California and recently in New York City. This is the greatest threat to our intensive care patients, not having appropriate staffing. And so thinking proactively with your staff, your nurses, your pharmacists, your EVS workers in order to ensure that you can incentivize them to stay is a strategy that we all need to be thinking about. Without our nurses, without our staff, we cannot take care of our patients. Okay, I'll stop there.

boarding in emergency departments

healthcare impact

delays in care

critical care admissions

COVID-19 impact