Longer Emergency Department Boarding Increases Risk of Patient Discrimination, Dissatisfaction

Situations when hospitalized patients remain in the emergency department (ED) for ≥24 hours are more frequently associated with instances of patient discrimination and risk of care dissatisfaction, according to new findings.1

In new data presented at the 2024 American College of Physicians (ACP) Internal Medicine Meeting in Boston, MA, this week, investigators from Harvard Medical School reported that ED boarding time may significantly impact the quality of care and treatment provided to patients. What’s more, the findings suggest the effect may be more severe for patients of marginalized races or ethnicities.

Led by Rose McKeon Olson, MD, MPH, of the division of global health equity at Brigham Women’s Hospital, the investigators sought to determine whether prolonged ED boarding is linked to increased risk of perceived discrimination and patient dissatisfaction, stratified by patient racial and ethnic background. As they noted, US EDs and hospitals have experienced “critical overcrowding and capacity challenges,” a trend exacerbated by the COVID-19 pandemic.²

“ED boarding is associated with adverse health outcomes,” they wrote. “Its effect on discrimination is unknown.”¹

The team conducted a random-sample survey at a large urban academic hospital from June 2023 – January, assessing hospitalized patients admitted to internal medicine care. Patients were stratified 1:1 as either identifying as non-Hispanic White, or being from a marginalized racial or ethnic background.

Length of boarding in the ED was stratified into 3 durations: <4 hours (reference group), 4 - <24 hours, and ≥24 hours. Olson and colleagues assessed for racial discrimination based on the Discrimination in Medical Settings Scale, and patient dissatisfaction based on the Adapted Picker Patient Questionnaire.

Their final analyses included 525 patients; 274 (52.7%) were from a marginalized race or ethnicity, and the rest were White. Mean patient age was 60.6 years old; 300 (57.1%) were female). Approximately 90% spoke English, and patients primarily had private insurance (47.2%), followed by Medicare (42.1%).

Patients were primarily onboarded in 4 - <24 hours at the ED (n = 202 [38.5%]), followed by ≥24 hours (n = 188 [35.8%]). Only one-fourth of patients were boarded within 4 hours. Such rates were consistent across both White and marginalized race / ethnicity cohorts.

Olson and colleagues reported that patients who were boarded for ≥24 hours were nearly twice as likely to report discrimination per questionnaire results (odds ratio [OR], 1.84; 95% CI, 1.05 – 3.24). Among the patients from marginalized racial / ethnic backgrounds, the risk was even more severe (OR, 2.18; 95% CI, 1.04 – 4.57; P = .04). Among White patients, the outcome was insignificant (OR, 1.37; 95% CI, 0.55 – 3.40; P = .05).

The investigators additionally observed that patients who were boarded ≥24 hours were 77% more likely to report dissatisfaction with their care (OR, 1.77; 95% CI, 1.02 – 3.08; P = .04).

“Hospitalized patients who board in the ED 24 hours or longer experienced more discrimination and dissatisfaction with their care,” the team wrote. “Despite similar lengths of boarding time, marginalized races and ethnicities were more likely to report discrimination during prolonged ED boarding.”

Though the assessment was limited by the single-center cohort and inability to adjust for potential confounders, among other shortcomings, the team believed the findings elucidated some clear needs for follow-up assessment.

Among those ideas, they noted, would be a qualitative study to identify the potentially modifiable drivers of discrimination in the ED, as well as a retrospective chart review to assess additional measures of boarding time outcomes.

References

1. ^{McKeon Olson R, Fleurant A, Beauparlant S, Baymon DE, et al. Emergency Department Board Associated with Increased Racial Discrimination and Patient Dissatisfaction. Poster presented at: American College of Physicians Internal Medicine 2024 Meeting. Boston, MA. April 18 – 20, 2024.}
2. ^{Alharthi S, Al-Moteri M, Plummer V, Al Thobiaty A. The Impact of COVID-19 on the Service of Emergency Department. Healthcare (Basel). 2021;9(10):1295. Published 2021 Sep 29. doi:10.3390/healthcare9101295}