title: The financial consequences of lost demand and reducing boarding in hospital emergency departments.
abstract: OBJECTIVE
  Some have suggested that emergency department (ED) boarding is prevalent because it maximizes revenue as hospitals prioritize non-ED admissions, which reimburse higher than ED admissions. We explore the revenue implications to the overall hospital of reducing boarding in the ED.
  
  
  METHODS
  We quantified the revenue effect of reducing boarding-the balance of higher ED demand and the reduction of non-ED admissions-using financial modeling informed by regression analysis and discrete-event simulation with data from 1 inner-city teaching hospital during 2 years (118,000 ED visits, 22% ED admission rate, 7% left without being seen rate, 36,000 non-ED admissions). Various inpatient bed management policies for reducing non-ED admissions were tested.
  
  
  RESULTS
  Non-ED admissions generated more revenue than ED admissions ($4,118 versus $2,268 per inpatient day). A 1-hour reduction in ED boarding time would result in $9,693 to $13,298 of additional daily revenue from capturing left without being seen and diverted ambulance patients. To accommodate this demand, we found that simulated management policies in which non-ED admissions are reduced without consideration to hospital capacity (ie, static policies) mostly did not result in higher revenue. Many dynamic policies requiring cancellation of various proportions of non-ED admissions when the hospital reaches specific trigger points increased revenue. The optimal strategies tested resulted in an estimated $2.7 million and $3.6 in net revenue per year, depending on whether left without being seen patients were assumed to be outpatients or mirrored ambulatory admission rates, respectively.
  
  
  CONCLUSIONS
  Dynamic inpatient bed management in inner-city teaching hospitals in which non-ED admissions are occasionally reduced to ensure that EDs have reduced boarding times is a financially attractive strategy.
authors.affiliation: Departments of Emergency Medicine and Health Policy, George Washington University, Washington, DC 20037, USA. jesse.pines@gmail.com
authors.forename: Jesse M
authors.initials: JM
authors.lastname: Pines
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Batt
authors.forename: Joshua A
authors.initials: JA
authors.lastname: Hilton
authors.forename: Christian
authors.initials: C
authors.lastname: Terwiesch
mesh_terms: D000328:Adult; D001509:Bed Occupancy / Q000191:economics* / Q000706:statistics & numerical data; D004636:Emergency Service, Hospital / Q000191:economics* / Q000706:statistics & numerical data; D005260:Female; D006746:Hospital Bed Capacity, 500 and over; D017722:Hospital Charges / Q000706:statistics & numerical data; D006760:Hospitalization / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay / Q000191:economics / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D018803:Models, Economic; D010045:Outpatients / Q000706:statistics & numerical data; D010343:Patient Admission / Q000191:economics / Q000706:statistics & numerical data; D011336:Probability