Leave Room for Safety When Boarding Patients in the ED

Two in every 5 emergency departments (EDs) report boarding times often exceed 24 hrs...to the point it’s now a US public health crisis.

Overcrowded emergency rooms are leading to rising deaths, increased costs, patient stress, staff burnout, etc. Even the public is taking notice due to popular TV shows such as The Pitt.

Help establish consistent protocols to care for ED boarder patients.

Med histories. We know med recs are vital for catching wrong doses, omitted drugs, etc...especially during transitions of care.

Prioritize interviewing boarder patients ASAP. Have pharmacy techs or interns assist with med recs if possible.

Pharmacist-led protocols. After doing med recs, advocate for a process where pharmacists can draft or pend home med orders for prescribers to sign, if appropriate.

This helps prevent delays in care...and decreases the chance of missing orders.

Similarly, a pharmacist-to-dose antibiotic protocol can help avoid subsequent missed doses during extended boarding periods...since ED patients are often prescribed one-time doses until they get to the unit.

Automated dispensing cabinets (ADCs). Designate an ADC machine in the ED to be stocked with common maintenance meds (PPIs, anti-seizure meds, antihypertensives, antidepressants, anticoagulants, etc).

Consider creating room-specific bins in the ADC to store maintenance meds that aren’t stocked. This helps ensure regimens are continued...nothing gets lost...and unused drugs can be returned.

Communication. Use the EHR to facilitate written communication between ED and floor unit staff. Place important reminders in handoffs, such as orders requiring follow-up, lab monitoring, etc.

Likewise, ensure the ED pharmacist attends boarder safety huddles to inform inpatient staff about boarding times, boarder patient volume, etc.

Help colleagues differentiate which ED patients are emergent cases versus boarders...to help ensure patients don’t fall through the cracks.

Effective workflows. Consider creating a “boarder service” for addressing the needs of boarder patients during busy times.

This team may consist of a prescriber, pharmacist, pharmacy tech, nurse, case manager, etc...and could help free up ED pharmacists and providers to care for non-admitted patients.

If this isn’t possible, ideally assign orders to the inpatient pharmacist who will care for the boarder patient after transfer. This helps decrease errors during the transition from the ED to the floor.

Optimize ED order sets to include continuing doses of critical meds for certain conditions (sepsis, etc) instead of only one-time orders.

• Checklist: Transitions of Care Checklist