Patients Prefer Inpatient Boarding to ED Boarding
Patients Prefer Inpatient Boarding to ED Boarding
The serious consequences of hospital crowding and ED boarding have been extensively documented and prior studies on the use of the FCP have supported its utility in impacting on consequences known to be harmful to patients. Despite its potential benefits, traditional objections to implementing FCPs include concerns that inpatient hallway boarding is unsafe and that patient satisfaction would be severely jeopardized. Prior studies at our institution have concluded that not only is inpatient hallway boarding safe in appropriate patients, but that prolonged boarding of ED patients in the ED hallways is unsafe.
The remaining objection to widespread implementation of the FCP is its potential negative impact on patient satisfaction. Several prior studies have attempted to address the impact of inpatient hallway boarding on patient satisfaction. A survey of admitted ED patients that were still in the ED by Garson et al. found that 59% preferred inpatient boarding and 41% preferred ED boarding. Another survey by Walsh et al. determined that 55% of admitted patients preferred inpatient hallways over ED hallways, and for their visitors, 66% preferred inpatient boarding. Most recently, Richards et al. surveyed 99 admitted ED patients who were awaiting bed assignments and found that 42% preferred to be boarded in inpatient hallways, 33% preferred to be boarded in ED hallways, and that 24% had no preference. A major limitation of these three studies was that none of the patients surveyed had actually ever experienced inpatient hallway boarding. Instead, patients were asked to hypothesize whether or not they would prefer the ED or inpatient location.
In contrast to prior studies, our study included patients who were actually boarded in the ED hallway and then the inpatient hallway during the same admission. We surveyed those patients who went from the ED hallway up to an inpatient hallway and asked them to compare their experiences in both places. Our study found that patients overwhelmingly preferred the inpatient hallway rather than the ED hallway when admitted to the hospital. Furthermore, ED patients appear to be very willing to be moved out of their ED rooms after being seen so that another patient can be seen, and support this practice for all patients. These results, paired with those mentioned previously, would suggest that what patients want most is to receive timely and effective care, even if it requires placement in a less than optimal setting.
As with any survey, several limitations apply to our study. Surveys conducted by telephone are, by their nature, restricted to patients with accurate, working numbers. Estimates of satisfaction might be subject to nonresponse bias. Although 105 of the 110 patients we contacted consented to participate in the study, we did not accurately track the number of noncontact cases (patients who boarded in the ED and acute care unit hallways and did not have a working telephone number for discharge follow-up). Our survey was conducted after hospital discharge and as such is subject to recall bias. Patients might not have been able to accurately recall or accurately match particular aspects of ED hallway or acute care unit hallway care. Although we could not verify that patients actually knew the difference between ED hallway and inpatient hallway admission, given our hospital geography (the inpatient floors are in a completely different tower, are much higher up, and are architecturally distinct from the ED layout), it is unlikely that patients confused the two locations. It is quite possible that patients' responses were influenced by social acceptability bias in which they wanted to feel like they were considerate of others in agreeing to be taken out of a room to a hallway. However, at the time of survey, patient's anonymity was guaranteed, reducing the likelihood that patients would respond in a way that differed from their true feelings.
Our study required development of a new patient satisfaction survey. We attempted to minimize instrument bias by following recommendations for survey research methodology. It is possible that our questions and Likert-scale responses might have been misleading or inappropriate. We attempted to limit instrument bias by pilot testing and revising the survey.
The responses collected were from a single, suburban academic hospital. The demographic profile of our region is largely Caucasian (87.5%), United States born (87.3%), English speaking (82.9%), with an educational attainment of high school graduate or higher (86.2%). Furthermore, our institution has nearly a decade of experience with acute care unit hallway boarding. Therefore, it might be difficult to generalize our results to other institutions.
Discussion
The serious consequences of hospital crowding and ED boarding have been extensively documented and prior studies on the use of the FCP have supported its utility in impacting on consequences known to be harmful to patients. Despite its potential benefits, traditional objections to implementing FCPs include concerns that inpatient hallway boarding is unsafe and that patient satisfaction would be severely jeopardized. Prior studies at our institution have concluded that not only is inpatient hallway boarding safe in appropriate patients, but that prolonged boarding of ED patients in the ED hallways is unsafe.
The remaining objection to widespread implementation of the FCP is its potential negative impact on patient satisfaction. Several prior studies have attempted to address the impact of inpatient hallway boarding on patient satisfaction. A survey of admitted ED patients that were still in the ED by Garson et al. found that 59% preferred inpatient boarding and 41% preferred ED boarding. Another survey by Walsh et al. determined that 55% of admitted patients preferred inpatient hallways over ED hallways, and for their visitors, 66% preferred inpatient boarding. Most recently, Richards et al. surveyed 99 admitted ED patients who were awaiting bed assignments and found that 42% preferred to be boarded in inpatient hallways, 33% preferred to be boarded in ED hallways, and that 24% had no preference. A major limitation of these three studies was that none of the patients surveyed had actually ever experienced inpatient hallway boarding. Instead, patients were asked to hypothesize whether or not they would prefer the ED or inpatient location.
In contrast to prior studies, our study included patients who were actually boarded in the ED hallway and then the inpatient hallway during the same admission. We surveyed those patients who went from the ED hallway up to an inpatient hallway and asked them to compare their experiences in both places. Our study found that patients overwhelmingly preferred the inpatient hallway rather than the ED hallway when admitted to the hospital. Furthermore, ED patients appear to be very willing to be moved out of their ED rooms after being seen so that another patient can be seen, and support this practice for all patients. These results, paired with those mentioned previously, would suggest that what patients want most is to receive timely and effective care, even if it requires placement in a less than optimal setting.
Limitations
As with any survey, several limitations apply to our study. Surveys conducted by telephone are, by their nature, restricted to patients with accurate, working numbers. Estimates of satisfaction might be subject to nonresponse bias. Although 105 of the 110 patients we contacted consented to participate in the study, we did not accurately track the number of noncontact cases (patients who boarded in the ED and acute care unit hallways and did not have a working telephone number for discharge follow-up). Our survey was conducted after hospital discharge and as such is subject to recall bias. Patients might not have been able to accurately recall or accurately match particular aspects of ED hallway or acute care unit hallway care. Although we could not verify that patients actually knew the difference between ED hallway and inpatient hallway admission, given our hospital geography (the inpatient floors are in a completely different tower, are much higher up, and are architecturally distinct from the ED layout), it is unlikely that patients confused the two locations. It is quite possible that patients' responses were influenced by social acceptability bias in which they wanted to feel like they were considerate of others in agreeing to be taken out of a room to a hallway. However, at the time of survey, patient's anonymity was guaranteed, reducing the likelihood that patients would respond in a way that differed from their true feelings.
Our study required development of a new patient satisfaction survey. We attempted to minimize instrument bias by following recommendations for survey research methodology. It is possible that our questions and Likert-scale responses might have been misleading or inappropriate. We attempted to limit instrument bias by pilot testing and revising the survey.
The responses collected were from a single, suburban academic hospital. The demographic profile of our region is largely Caucasian (87.5%), United States born (87.3%), English speaking (82.9%), with an educational attainment of high school graduate or higher (86.2%). Furthermore, our institution has nearly a decade of experience with acute care unit hallway boarding. Therefore, it might be difficult to generalize our results to other institutions.
