Reduced Functional Bed Capacity Due to Boarding Predicts Increased Rates of Left-Without-Being-Seen (Quality and Patient Safety Interest Group Sponsored)

Background and Objectives: As emergency department (ED) crowding continues to rise nationally, so has the percentage of patients who leave-without-being-seen (LWBS). We sought to evaluate the relationship between boarding of admitted inpatients in the ED, which we measured as functional bed capacity (FBC), and rates of LWBS. FBC is defined as the mean percent of ED beds available for new patients over a 24-hour period.

Methods: We performed unadjusted and adjusted quantile regression models predicting LWBS by FBC terciles (low, medium, and high) compared to median admit-to-departure (A2D) times. Study sites included one academic, one community, and one pediatric ED in a single, urban medical system. We additionally studied the effects of other operational metrics on LWBS, including daily census and length of stay of discharged patients (LOSD).

Results: Our study included 373,388 visits across the three hospitals. In the aggregate adjusted regression, low FBC was associated with 1.59% higher LWBS compared to high FBC, which represents a 26.5% relative increase in comparison to the median LWBS. Larger daily census (p < 0.001), longer LOSD (p < 0.001), and seasons of fall (p < 0.001) and summer (p < 0.01) relative to winter were also significantly associated with increased LWBS. Weekdays relative to weekend days (p < 0.001) were significantly associated with decreased LWBS. Substituting median A2D in place of FBC results in comparable model performance with a smaller effect size. In the aggregate model, every additional 20 minutes in median A2D predicted a 0.1% rise in LWBS.

Conclusion: FBC is a new, pragmatic operational metric strongly associated with LWBS and easily measured in a variety of ED settings. This retrospective, observational, multi-site study shows that worsening FBC and A2D predict an increase in LWBS rates, with FBC showing a larger effect. We propose using FBC as a metric in future studies within ED operations. Additional studies that incorporate staffing levels to more accurately approximate FBC and better characterize the true impact of FBC on LWBS rates are needed, as is research to better characterize patients who LWBS, their clinical outcomes when available, and the economic consequences of losing these encounters.

Presenter:

  • Yosef Berlyand, MD
Authors

  • Yosef Berlyand, MD

    Warren Alpert Medical School of Brown University

    Yosef Berlyand, MD, is the Associate Director of Quality and Patient Safety and Associate Director of the Division of Emergency Department Operations and Quality Improvement at Brown Emergency Medicine. He is also an Assistant Professor of Emergency Medicine at The Alpert Medical School of Brown University.

    Within SAEM, Dr. Berlyand serves as Chair of the Quality and Patient Safety Interest Group and a member of the ED Administration and Clinical Operations Committee. He has published research on patient experience, emergency department operations, home-based hospitalization, ED observation units, and improvements in sepsis care. Additionally, his work in NEJM Catalyst highlights the development and implementation of an innovative electronic pass-off system in the ED.

    He earned his medical degree from Harvard Medical School and completed his emergency medicine residency at the Harvard-Affiliated Emergency Medicine Residency at Massachusetts General Hospital and Brigham and Women’s Hospital.

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