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Effective emergency department (ED) patient flow has multiple benefits to the patients, staff, and hospital. To ensure optimal flow within the ED, attention must be directed toward the 3 critical aspects of the patient's management, (1) door to doctor (arrival to practitioner), (2) doctor (evaluation) to disposition decision, and (3) disposition decision to actual disposition. Interruption to, or barriers to progression of, any of these components can lead to prolonged delays, dissatisfaction, and financial loss.

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A major barrier to ED flow occurs when admitted patients are held in the ED (boarders). ED overcrowding (crowding) is most often the result of the boarding of admitted patients.1 ED crowding occurs when ED beds are occupied leading to a delay in the evaluation and management of the next waiting patients. The inability to move admitted patients to inpatient beds is the primary cause

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Inpatients boarding in the ED occupy beds and consume resources that are meant for and best reserved for new ED patients.2

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“When a hospital is full, emergency department patients who need inpatient care are ‘boarded' in exam rooms or hallways until an inpatient bed is available. Boarding ties up space, equipment, and personnel that would otherwise be available to meet the needs of incoming patients. Critically ill patients often wait the longest for admission, because beds in the intensive care unit are in particularly short supply.”

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There is an extensive body of literature on the negative impact of boarders in the ED (Table 37-1).1,3

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Table 37-1 Ramifications of ED Crowding
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The resolution of this critical and dangerous problem can only result from the recognition and collaboration of the hospital administration, board, ED leaders, and inpatient services. The solution requires the combined efforts of the stakeholders to “alleviate the bottleneck caused by emergency patients waiting for inpatient beds.”

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Progressive patient-centered institutions develop processes to “break the bottlenecks” by creating admission protocols that move patients quickly from the ED to inpatient beds. A number of strategies are recommended by the authors of this chapter to help decrease ED boarding and accelerate the admission of patients into the hospital.

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Early Decision to Admit

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In most cases, an experienced emergency physician knows whether a patient needs hospital admission within minutes of entering ...

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