SEE RELATED ARTICLE, P. 9.
[Ann Emerg Med. 2008;51:13-14.]
The maturing science of the causes and consequences of boarding of admitted patients demonstrates unequivocally the dangers the patient may face when entering a crowded emergency department (ED).1 Even the demonstration of increased mortality rates associated with crowding2, 3 has not compelled the hospital industry as a whole to implement policies and procedures to ameliorate crowding. However, a Trojan horse, patient satisfaction scores, might provide a call to action where literature of greater desperation has failed. It is in this spirit that Garson et al4 examine patient preferences for boarding locations when hospitals are at full capacity.
Specific details of the study are crucial to understanding the seemingly modest results. First, 90% of the patients included in the survey were boarded in rooms in the ED, rather than an ED hallway. Second, no patients at this institution are actually boarded in hallways on inpatient units. Thus, few patients in the survey had firsthand experience of “in-hallway boarding” to make their choice more meaningful. Despite this, a modest preference for inpatient boarding still existed. In this study, 36% of patients had no preference, and those expressing a preference favored inpatient versus ED hallway placement at a preference split of 60%/40%.
Were the right questions being asked? The patients received no context for the question. Survey results are heavily influenced by the presence or absence of contextual information. For instance, the question “Would you object to a 5% tax increase?” might get a very different response than “Would you object to a 5% tax increase if, in return, your family received a free education, free health care, a free retirement fund, a free house, and a free car?”
Our experience with patient preference is quite different.5 Our institution has experience in placing several thousand patients on inpatient units in the hallway. When we started this process, our bed coordinator queried patients as to their preferred location for boarding once they were placed on the inpatient unit. This differs from Garson et al4 in that our patients had firsthand experience with being boarded in both areas, and ours stated an overwhelming preference for boarding in the inpatient unit. Our program also helped increase our patient satisfaction scores (for which we received a national award).
A well-staffed and well-equipped ED can be brought to its knees with high capacity and barriers to outflow (hence, admitted boarders). This places the well-being of our patients in jeopardy, a risk that may be “out of sight” of many elsewhere in the hospital, which is why we put effort into reducing or eliminating the practice of boarding admitted patients in the ED.
Given that backdrop, imagine what the results of the survey might have been had the following questions and context been used:
You are now being admitted and we would like to ask you a series of questions related to your personal preferences about your admission. Because we need rooms to treat new patients, we may have to move you to the hallway, just as we did to previous patients so that we could treat you. The following questions will help us understand whether you would prefer to be boarded in the ED hallway or on an inpatient unit in their hallway.
A.Would you prefer being in an area of higher or lower risk of medical error?
B.Would you prefer being in an area with better or worse nurse-to-patient ratios?
C.Would you prefer being in an area staffed by nurses who specialize in caring for your particular problem?
D.Would you prefer being in an area where you are nearer to the inpatient specialist caring for you?
E.Would you prefer being in an area where you will get out of the hallway and into a normal room quicker?
F.Would you prefer being in a quiet or noisy environment?
G.Would you prefer being in an area where you might get a good night’s sleep?
H.Would you prefer an area where breakfast, lunch, and dinner are routinely served?
I.If you have to share a bathroom, would you rather share with 1 other person or 50?
J.Do you want your family to visit you and know what’s going on, or do you want everyone’s family to visit you and know what’s going on?
K.Do you prefer an area with some privacy or an area with no privacy?
L.Would you prefer being placed in an area where your total length of stay in the hospital will be longer or shorter?
It is difficult to imagine that questions such as the ones just listed would result in no preference or a 60%/40% split.
One might argue that the Garson et al4 questions are more neutral and therefore more valid. I would argue that this is exactly what makes these questions invalid. The experience of the patient boarded in the ED is entirely different from the experience of the patient boarding on an inpatient unit. Surveys that erase these differences lessen our understanding of what the patient wants or needs.
In the end, if we care about what the patient wants, we must ask the right questions. Better, we should show interest in what the patient needs. Inpatient boarding is not “the” solution, but it is part of a solution to capacity demands and ED crowding. It correctly involves the institution in what is, in truth, an institutional capacity problem.
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