The Commonwealth of Massachusetts

Executive Office of Health and Human Services
Department of Public Health
Division of Health Care Quality
99 Chauncy Street, 2nd Floor, Boston, MA 02111
617-753-8000

DEVAL L. PATRICK
GOVERNOR
TIMOTHY P. MURRAY
LIEUTENANT GOVERNOR
JUDYANN BIGBY, MD
SECRETARY
JOHN  AUERBACH
COMMISSIONER	

Circular Letter: DHCQ-09-07-513

TO: 		Hospital Chief Executive Officers 

FROM: 	Paul Dreyer, Ph.D. 
Bureau Director 
		
DATE: 	July 8, 2009

SUBJECT: 	Boarding of Emergency Department (ED) Patients Awaiting a Bed

In January of 2009, Massachusetts became the first state to eliminate ambulance diversion as an option to address ED crowding.  This policy decision was based on evidence showing that diversion is not effective in reducing ED crowding and that it creates additional issues for patients, prehospital providers, and hospitals.  We are pleased with the indicators of the success of this policy.

The goal of all of our efforts to eliminate ED crowding is to maintain the hospitals’ capacity to accept and manage new patients presenting for emergency care, which requires that hospitals move admitted patients out of the ED as quickly and safely as possible.  Numerous studies have shown that boarding patients in the ED is associated with adverse clinical outcomes.

We have previously identified best practices hospitals should consider to reduce ED boarding.  One effective and safe strategy hospitals should consider to reduce the boarding of patients in EDs is to transfer specific types of stabilized patients to inpatient units while they are awaiting a bed.  This letter reaffirms the Department’s policy regarding the placement of patients on inpatient units in appropriate alternative space while they await admission to an inpatient bed.  The Department’s original policy statement and protocol are attached to this letter and can also be found on the Department’s website at: http://www.mass.gov/Eeohhs2/docs/dph/quality/healthcare/ad_emergency_management.pdf

The Department has worked with several groups to ensure the appropriateness of its corridor boarding policies.  The Massachusetts Hospital Association (MHA), the Massachusetts Organization of Nurse Executives (MONE), and the Massachusetts College of Emergency Physicians (MACEP) are all in support of the Department’s policies around the use of corridor beds.  The Boarding and Patient Flow Task Force, which includes members from emergency departments, hospitals, professional associations and Emergency Medical Services, has also expressed strong support for the use of inpatient corridor boarding under the prescribed conditions.

The Department has worked collaboratively with the Department of Fire Services (DFS) to address hospital fire protection and evacuation plans relative to the ongoing issues of hospital emergency department crowding and patient boarding.  Hospitals have been encouraged to work with their local fire departments to ensure that their plans are up to date. A memo from the Fire Marshal to Heads of Fire Departments about this topic can be found at: 
http://www.mass.gov/Eeohhs2/docs/dph/quality/hcq_circular_letters/memo_fire_depts.pdf

Patients who require specialized monitoring may not be boarded in corridors using these protocols.  In fact, hospitals should consider transferring patients who require critical care or monitoring if they cannot be accommodated in a timely way.

The goal of the Department’s work with the Boarding and Patient Flow Task Force is to reduce and where and when possible to eliminate the boarding of inpatients in EDs,  in order to alllow for the timely and efficient care of incoming sick and injured patients. We appreciate the efforts everyone has made to date to assure the success of our policy restricting ambulance diversion. The Task Force is now focused on impediments to psychiatric patient flow and collection of boarding data in the interest of further reducing ED crowding in our state.

Please contact Gail Palmeri at (617) 753-8230 for further information about this policy.