Original Article

CME Article: A Hospitalist-Led Team to Manage Patient Boarding in the Emergency Department: Impact on Hospital Length of Stay and Cost

Authors: Alexander Hrycko, MD, Vishal Tiwari, MD, Michael Vemula, MD, Ashley Donovan, BS, Christine Scibelli, RN, Kirti Joshi, MD, Paul Visintainer, PhD, Mihaela S. Stefan, MD, PhD


Objectives: Admitted patients boarding in the emergency department (ED) while awaiting inpatient beds represent a bottleneck in patient flow. We sought to examine the impact on patient flow and potential for cost savings by an active management of boarded ED medical admissions by a hospitalist-led team, which included a hospitalist, an advanced practitioner, and a case manager.

Methods: This was a retrospectively conducted analysis of a quality improvement pilot intervention implemented at a large tertiary center. We analyzed patients admitted under observation status between April 1, 2016 and June 30, 2016. We calculated the difference for length of stay (in hours) and direct cost between patients in the intervention group and a usual care group from a similar time period in the prior year matched on the all patients refined-diagnosis related groups (APR-DRG) and severity of illness (SOI) level.

Results: One hundred seventy-five observation patients were managed by the hospitalist team during the 3-month pilot period. This group had an average hospital stay of 26.0 hours compared with 29.7 hours in the usual care group. Direct costs resulted in the following results: average cost for the intervention patient group $1452 (±$775) versus $2524 (±$894) group, for an average savings of $1072 (P < 0.001), with a total estimated direct cost savings of $187,660.

Conclusions: Active management of ED boarding patients by a hospitalist-led team is feasible and can lead to hospital cost savings and decrease in hospital stay. The findings from this pilot resulted in a decision to make the ED hospitalist-led team permanent in our institution. The evaluation of the program may help other hospitals to decide whether this intervention is worth pursuing in their own organization.

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.


1. Chadaga SR, Shockley L, Keniston A, et al. Hospitalist-led medicine emergency department team: associations with throughput, timeliness of patient care, and satisfaction. J Hosp Med 2012;7:562-566.
2. Forster AJ, Stiell I, Wells G, et al. The effect of hospital occupancy on emergency department length of stay and patient disposition. Acad Emerg Med 2003;10:127-133.
3. Bornemann-Shepherd M, Le-Lazar J, Makic MB, et al. Caring for inpatient boarders in the emergency department: improving safety and patient and staff satisfaction. J Emerg Nurs 2015;41:23-29.
4. Horwitz LI, Meredith T, Schuur JD, et al. Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care. Ann Emerg Med 2009;53:701-710.e4.
5. Singer AJ, Thode HC, Jr Viccellio P, et al. The association between length of emergency department boarding and mortality. Acad Emerg Med 2011;18:1324-1329.
6. McCaughey D, Erwin CO, DelliFraine JL. Improving capacity management in the emergency department: a review of the literature, 2000-2012. J Healthc Manag 2015;60:63-75.
7. Howell E, Bessman E, Kravet S, et al. Active bed management by hospitalists and emergency department throughput. Ann Intern Med 2008;149:804-811.
8. Healthcare Cost and Utilization Project. All patient refined diagnosis related groups (APR-DRGs). https://www.hcup-us.ahrq.gov/db/nation/nis/APR-DRGsV20MethodologyOverviewandBibliography.pdf. Published 2003. Accessed June 1, 2019.
9. McCormick PJ, Lin HM, Deiner SG, et al. Validation of the all patient refined diagnosis related group (APR-DRG) risk of mortality and severity of illness modifiers as a measure of perioperative risk. J Med Syst 2018;42:81.
10. Romano PS, Chan BK. Risk-adjusting acute myocardial infarction mortality: are APR-DRGs the right tool? Health Serv Res 2000;34:1469-1489.
11. Haq N, Stewart-Corral R, Hamrock E, et al. Emergency department throughput: an intervention. Intern Emerg Med 2018;13:923-931.