DHA 700 Week 8 Scholarly Paper on a Health Administration Problem Example

The Hallway Is Not a Ward: A Scholarly Analysis of Emergency Department Boarding at a Rural Regional Hospital and an Evidence-Informed Plan to Reduce It

[Student Name]

University of Phoenix

DHA/700: Introduction to Health Administration in Doctoral Study

Week 8 Assignment

[Instructor Name]

[Date]

The rural health system, its hospital, boarding data, causes and plan are composites written for a model paper; research findings come from the sources cited.

On a January night, 23 admitted patients waited in the emergency department of the composite rural health system's 180-bed regional hospital, some on stretchers in hallways. Ambulances were diverted to a hospital forty minutes away. Nurses cared for both emergency and inpatient patients at once. The next morning, the chief operating officer asked a question that became the focus of her doctoral work: why does this happen, and what can be done? This paper analyzes boarding at the hospital and proposes an evidence-informed plan to reduce it.

Defining the Problem

Boarding refers to admitted patients who remain in the emergency department after the decision to admit because no inpatient bed is available. At the regional hospital, admitted patients typically spent seven hours in the department after the admission order was written during the previous winter, and 14% of admitted patients waited more than twelve hours. On the worst days, boarded patients occupied more than half of the department's treatment spaces, leaving few for new arrivals and forcing some to wait in the lobby.

Why Boarding Matters: Mortality and Length of Stay

Boarding is associated with harm. In a cohort of 41,256 admissions at an academic emergency department, patients boarded twelve hours or more had in-hospital mortality of 4.5%, compared with 2.5% for those boarded under two hours, and length of stay rose with boarding time, associations that persisted after adjustment for comorbid conditions (Singer et al., 2011). The pattern suggests that each additional hour in a space designed for emergencies rather than inpatient care carries risk.

Why Boarding Matters: Across a State

Evidence across many hospitals points the same way. Among nearly one million admissions through 187 California emergency departments, patients admitted on each hospital's most crowded days had 5% higher odds of inpatient death, slightly longer stays and higher costs, which the authors translated into roughly 300 additional deaths statewide over the study year (Sun et al., 2013). A problem that looks like congestion on a dashboard shows up as deaths in a state's records.

A Framework for Causes

To find causes, the paper uses a conceptual model that divides emergency department crowding into three interdependent components: input, the demand for emergency care; throughput, what happens to patients once inside; and output, the ability to get admitted patients out to inpatient units, all within an acute care system built around unscheduled care (Asplin et al., 2003). The model directs attention to where the flow actually stops.

Input

Emergency visits at the regional hospital grew 9% in three years as the system's smaller hospitals reduced services and a nearby urgent care center closed. Yet visits per day in winter were only modestly higher than in summer, while boarding tripled. Input contributes but is not the main driver.

Throughput

Throughput was reasonably efficient. Median time from arrival to decision to admit was under four hours, comparable to peers. Laboratory and imaging turnaround times met targets. Improving throughput alone would move patients to the decision to admit faster but would not create beds.

Staff and Patient Experience

Boarding affects people as well as numbers. Emergency nurses described caring for boarded inpatients while triaging new arrivals, missing medication times and feeling unable to give either group proper attention. Patients described nights on hallway stretchers under bright lights, with little privacy and delayed meals. Several nurses cited boarding as a reason they were considering leaving, linking the problem to the workforce challenges analyzed earlier in the course.

Output: The Main Constraint

Output was the bottleneck. Inpatient occupancy exceeded 95% on most winter weekdays. Discharges clustered in the late afternoon, after most admission decisions had been made. Elective surgical admissions peaked on Tuesdays and Wednesdays, consuming beds on the same days emergency admissions rose. And an average of eleven patients each day were medically ready for discharge but waiting for nursing home or home health placement.

The Case for Smoothing

One output cause is self-inflicted. Litvak and Fineberg argue that much of the variability in hospital census comes not from unpredictable emergencies but from the way elective admissions are scheduled, and that smoothing elective schedules can reduce overcrowding, improve safety and lower costs, citing hospitals that redesigned surgical scheduling (Litvak & Fineberg, 2013). The regional hospital's midweek surgical peaks fit that description.

Solution One: Smooth Elective Surgery

The hospital will analyze elective admissions by day and redistribute cases requiring inpatient beds more evenly across the week, reserving capacity on days with the highest emergency admissions. Surgeons will be engaged early, since block times are valued.

Solution Two: Earlier Discharges

Units will set a goal of 35% of discharges before noon, supported by discharge planning that begins at admission, next-day discharge orders written the evening before, pharmacy and transport scheduled early and a lounge near the main entrance where discharged patients can wait for family to collect them.

Solution Three: A Capacity Command Center

A small command center will monitor beds, admissions, discharges and emergency department status in real time, hold huddles three times daily and activate a surge plan when boarding exceeds a threshold, moving boarded patients to inpatient hallways, where inpatient nurses care for them, rather than keeping them in the emergency department.

Solution Four: Post-Acute Partnerships

The system will create partnerships with three nursing homes and two home health agencies, with shared liaisons, priority admission agreements for medically ready patients and a small fund to cover gaps in coverage that delay placement.

Implementation

The chief operating officer will sponsor the plan, with the chief nursing officer leading discharge and command center work, the surgical chair leading scheduling changes and the director of case management leading post-acute partnerships. Implementation will proceed in phases over twelve months.

Evaluation

The evaluation will track median boarding time, the percentage of patients boarding more than twelve hours, ambulance diversion hours, discharges before noon, daily variation in elective admissions, days waiting for post-acute placement and, as balancing measures, readmissions and patient experience. An interrupted time series comparing monthly results before and after each change will estimate effects, with seasonal adjustment.

Limitations

The evidence linking boarding to mortality is observational, so reducing boarding may not produce the full benefit these studies suggest. Evidence on specific interventions is weaker and comes mostly from larger urban hospitals. The hospital's small size makes monthly results volatile.

Implications

For leaders, the analysis suggests treating boarding as a hospital-wide safety problem rather than an emergency department problem, since its main causes lie in inpatient flow and post-acute capacity. For research, a careful evaluation in a rural hospital could add evidence where little exists.

Conclusion

Boarding at the regional hospital is common, harmful and caused mainly by output constraints. Evidence links boarding and crowding to higher mortality and costs, a conceptual model locates causes in inpatient flow and an argument for smoothing elective admissions points to a cause the hospital controls. Four matched solutions, a phased implementation and an interrupted time series evaluation form a plan the system can test, and its results can contribute rural evidence to the field.

References

Asplin, B. R., Magid, D. J., Rhodes, K. V., Solberg, L. I., Lurie, N., & Camargo, C. A., Jr. (2003). A conceptual model of emergency department crowding. Annals of Emergency Medicine, 42(2), 173-180. https://doi.org/10.1067/mem.2003.302

Litvak, E., & Fineberg, H. V. (2013). Smoothing the way to high quality, safety, and economy. New England Journal of Medicine, 369(17), 1581-1583. https://doi.org/10.1056/NEJMp1307699

Singer, A. J., Thode, H. C., Jr., Viccellio, P., & Pines, J. M. (2011). The association between length of emergency department boarding and mortality. Academic Emergency Medicine, 18(12), 1324-1329. https://doi.org/10.1111/j.1553-2712.2011.01236.x

Sun, B. C., Hsia, R. Y., Weiss, R. E., Zingmond, D., Liang, L., Han, W., McCreath, H., & Asch, S. M. (2013). Effect of emergency department crowding on outcomes of admitted patients. Annals of Emergency Medicine, 61(6), 605-611. https://doi.org/10.1016/j.annemergmed.2012.10.026