The Boarded Patient

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LNCtips.com: The Boarded Patient


Hospital administrators, emergency department (ED) physicians and ED staff all agree that boarding patients in the emergency department is an undesirable situation.  A boarded patient is one who has been accepted for admission to an inpatient unit but hasn't been transferred, often because no inpatient bed is available.  In addition to being an unpleasant experience for patients, boarding can also lead them to file medical malpractice claims.

After assessment by the triage nurse, patients are taken to rooms and evaluated by ED physicians.  The ED physicians may order diagnostic tests and/or perform procedures while the patients are in the ED.  ED staff members monitor the patients, ensure that diagnostic tests are performed, administer medications, treat and stabilize patients, and inform the ED physicians of changes in patients' condition. 

Not every patient is admitted, of course, but when a patient is, the ED physician notifies the attending physician and provides a report on the patient's condition. In many medical centers, a hospitalist, who may have a dedicated desk in the ED, is the attending physician.  After hearing the report from the ED physician, the attending physician provides admission orders.  At that point, the ED physician's responsibility is finished unless ED nurses re-engage him or her for emergent condition changes or orders if the nurses are unable to speak with the attending physician.  

The admission orders include the nursing unit (e.g., Telemetry, 2 South, CCU, etc.) where the patient is to be placed.  The admitting department or "bed board" is also notified of the admission.  If no bed is immediately available on the desired nursing unit, the patient remains in the ED.  Because nurses from the various nursing units can't leave their units to provide care to boarded patients, ED nurses retain this responsibility until the patient is transported to an inpatient bed.

This transition time while the patient is in ER waiting for an inpatient bed is where patients frequently allege medical malpractice.  The most common allegations that I see involving boarded patients are failure to timely treat and failure to appropriately monitor patients. 

Part of the problem is that there may be a misunderstanding of the ED physician's role.  Some patients expect the ED physician to care for them until they are physically transported to an inpatient unit.  However, as one ED physician told me, "I'm not a house physician.  I can't treat ED patients and boarded patients too."

ED nurses also can't function as house nurses, and that creates another part of the problem. ED nurses carry out some of the admission orders, but not all of them.  For example, they might administer important medications but not all medications.  ED nurses often don't contact consulting physicians unless the attending physician specifically requests them to.  They don't apply sequential compression devices, for example, but they will assess the boarded patient for pain, take vital signs, and monitor for condition changes.

As a result of this, there often is a delay in treatment and interventions until the patient is transported to an inpatient bed.  For example, one of my recent cases involves a patient who was boarded for six hours in the ED.  As a result, the plaintiff alleged that an epidural lumbar abscess went undetected resulting in paraplegia.

As a legal nurse consultant, one of your responsibilities when reviewing medical records of boarded patients is to determine if important medications, tests, and treatments ordered by the attending physician were provided in a timely manner. The definition of "important" will vary from case to case.  

A second LNC responsibility is to determine if the patient was appropriately monitored.  For example, if the attending physician ordered neuro assessments, did the ED nurses perform them or did they only assess vital signs?

A third LNC responsibility is to determine if the ED nurses reported changes of condition.  If they did report condition changes, to whom did they report the changes, the ED physician or the attending?

A fourth LNC responsibility is to determine if the patient's damages occurred as a result of being boarded.  Ask yourself, "Would the patient have suffered the same damages if he or she had been transported immediately to the inpatient unit?"  I've reviewed medical malpractice cases in which the delay made a difference and cases in which the delay made no difference in the patient's damages.

Thanks go to Emily Flynn for her assistance with this topic.

...Katy Jones