Hospital Boarding Crises: The Impact of Urgent vs. Prevention Responses on Length of Stay

Healthcare policy makers use wait-time metrics to encourage hospital managers to improve patient experience. In 2002, Massachusetts mandated that hospital managers develop processes to respond to boarding crises, which occur when emergency department (ED) patients experience long waits for inpatient beds. Performance improvement theory suggests that patients would be better served by preventing boarding crises rather than responding urgently after they occur. To empirically test this theory, we use data from a Massachusetts hospital that has two physician-based processes related to boarding and patient flow. First, to comply with the state mandate, the hospital developed processes to identify when the hospital is in a boarding crisis, a code yellow (CY), and subsequently request that physicians prioritize patient discharge (urgent response). Second, physicians can use predischarge orders, optional written communication about discharge barriers, to avoid discharge delays for patients approaching discharge (prevention response). Our data supports the existence of a trade-off between these two responses. Counter to our hypothesis, the state-mandated urgent response does not have any impact on length of stay (LOS). We also find that a CY has no impact on ED hourly occupancy, marginally decreases ED wait times, and increases boarding time. The prevention response is associated with a 26% reduction in LOS. Furthermore, we find that the urgent response reduces the likelihood of physicians' ability to use the prevention response by 27.3%. We conclude that the state policy has unintended negative consequences that stymie hospital efforts to create longer term improvement.