In 2008, an American College of Emergency Physicians task force released a report on high-impact solutions to ED boarding. Item No. 1 on the solutions list was what has come to be known as a “full capacity protocol.”
The cornerstone of that protocol is moving boarded patients waiting for inpatient beds out of the ED and into inpatient areas of the hospital including inpatient hallways and conference rooms. (Other high-impact solutions proposed: coordinating discharge before noon, maintaining observation units and smoothing out surgery schedules that are top-heavy at the beginning of the week.)
Over the years, the full capacity protocol—sometimes called capacity or escalation protocol—has gained some traction internationally, but not in the U.S. For a 2019 article in Implementation Science, “What is full capacity protocol, and how is it implemented successfully?,” researchers conducted more than 30 interviews in academic centers around the country to see what worked in terms of protocol adoption and what didn’t.
Barriers include a lack of physical space and a shortage of inpatient nurses.
Two-thirds of those centers had implemented such a protocol. The rest had considered doing so but found barriers to be too high.
What were those barriers? Not surprisingly, interviews cited a lack of physical space and a shortage of inpatient nurses—and this was published before the pandemic pushed nurses out of hospitals in droves. The potential for increased work on inpatient nurses was also listed as a problem, and some hospitals that tried adopting the protocol ran into trouble with fire marshals for putting patients in the halls.
Researchers found another mindset mentioned as a barrier to adopting full capacity protocol: the idea that ED boarding is the ED’s problem alone and one that doesn’t warrant a hospital-wide response.
With the proliferation of boarding issues in hospitals across the country, it’s interesting to ask whether that attitude is still prevalent. Are hospitals increasingly swamped with ED boarders more willing to give such protocols a try?
According to Gregg Miller, MD, an emergency physician and chief medical officer of Vituity, a physician-led multispecialty partnership at more than 500 hospital locations nationwide, the use of such protocols in hospitals is “still very uncommon.”
“Where we have implemented it,” Dr. Miller says, “it has been for patients with an assigned bed that will turn over very soon”—such as one waiting for environmental services to come clean it. “Patients don’t board in an inpatient hallway indefinitely.”
He admits that the protocol is a challenge for overstretched inpatient nurses. But he also notes that inpatient hallway boarding can prevent EMS from waiting hours to offload patients, putting paramedics back into the community for 911 calls sooner. It may also open up an ED bed sooner and prevent patients from leaving the ED without being seen.
And “patients being boarded often prefer a calmer inpatient hallway than the chaos in the ED.”
IN NOVEMBER 2022, the American College of Emergency Physicians, along with more than 30 other medical associations and advocacy groups, sent a letter to the White House, detailing the burden and dangers of ED boarding, including deaths taking place among boarded patients. For more on ED boarding, read Is your ED snarled with boarders?
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
