D458 Task 2 Systems Thinking Solution Example

The Backup Starts Upstairs: A Systems Thinking Analysis of Emergency Department Boarding Across Three Composite Community Hospitals and a Solution Designed for the Whole Region

Student Name

Leavitt School of Health, Western Governors University

D458: Introduction to Systems Thinking for Health Professionals, Task 2

Course Instructor

Month Day, Year

The Backup Starts Upstairs: A Systems Thinking Analysis of Emergency Department Boarding Across Three Composite Community Hospitals and a Solution Designed for the Whole Region

The Problem

Administrators from three composite community hospitals in one region, Riverside, St. Anne's and Valley Medical, met because their emergency departments had the same problem. On most weekday afternoons, admitted patients waited in emergency department hallways for inpatient beds, often for eight hours or more and sometimes overnight. Waiting room times grew, patients left without being seen, and ambulances were diverted from one hospital to the next, which simply moved the crowd. Each hospital had tried its own fix. Riverside added six emergency department beds; St. Anne's hired more emergency physicians; Valley Medical opened a fast-track area for minor injuries. Within a year, boarding at all three was as bad as before.

Seeing the System

Emergency department crowding is best understood as a flow problem with three parts: input, the patients arriving; throughput, the care delivered in the department; and output, the movement of patients out, especially admitted patients to inpatient beds (Asplin et al., 2003). The three hospitals had focused on input and throughput. Riverside's new beds and St. Anne's new physicians increased throughput, and Valley Medical's fast track moved minor cases more quickly. None of them changed output. When the inpatient units are full, every admitted patient stays in the emergency department, occupying a bed and a nurse, so improving throughput only fills the department with boarders faster.

Boarding matters for patients. A systematic review of 12 studies on boarding and in-hospital mortality found that six reported an association, five did not and one had mixed results; the authors concluded that the evidence was not strong but showed a tendency toward higher mortality with longer boarding (Boudi et al., 2020). Boarding also delays care for patients still in the waiting room and exhausts staff.

The Feedback Loops

Systems thinking is suited to problems like this one, in which many actors and feedback loops interact and simple fixes produce unexpected results (Peters, 2014). Four loops explain why boarding persists.

The first is a reinforcing loop of staff strain. Boarding increases nursing workload in the emergency department; heavier workload increases burnout and turnover; turnover leaves fewer nurses, which slows care and lengthens stays, which increases crowding and boarding. The loop feeds on itself.

The second is a reinforcing loop through diversion. When one hospital diverts ambulances, its neighbors receive more patients, become crowded and divert in turn. Because the three hospitals do not coordinate, diversion moves the problem around the region without reducing it.

The third is a balancing loop that should limit boarding but is delayed. As boarders accumulate, pressure grows to discharge inpatients, but most discharges happen in the mid-afternoon, after physicians' rounds, pharmacy reconciliation and transportation are arranged. The balancing effect arrives hours after the peak of emergency admissions in late morning.

The fourth concerns patients who need behavioral health care. Adults and adolescents in psychiatric crisis may board for days while staff search for an available psychiatric bed in the region. Each such patient occupies an emergency bed for far longer than a medical admission, reducing capacity for everyone else.

Why Past Fixes Failed

Seen through these loops, the earlier fixes were symptomatic solutions. More emergency beds and physicians increased throughput without changing output, so they filled faster with boarders. The fast track helped patients with minor injuries but did nothing for admitted patients. Each fix also sat inside one hospital's boundaries, while the diversion loop crosses boundaries. A systems view predicts exactly what happened: the problem returned because the structures producing it were unchanged.

A Solution for the Whole System

The proposed solution has four parts, each aimed at a loop.

First, move discharges earlier. Each hospital will set a goal of discharging a third of the day's planned discharges before noon, supported by identifying next-day discharges the afternoon before, completing medication reconciliation and arranging transportation in advance, and using a discharge lounge where patients can wait for rides. This shortens the delay in the balancing loop so beds open when emergency admissions peak.

Second, create a regional capacity center. The three hospitals will share real-time data on available beds and emergency department status through a single dashboard, staffed by a nurse coordinator who can arrange transfers among them. Diversion will be permitted only through the center, which breaks the reinforcing diversion loop by making the region, not each hospital, the unit of planning.

Third, build a behavioral health pathway. The hospitals will jointly fund a regional crisis stabilization unit with 12 observation beds, to which emergency departments can transfer patients in psychiatric crisis within hours, and a shared telepsychiatry service to assess patients promptly. This removes the longest boarders from emergency beds.

Fourth, protect emergency staff. When boarding exceeds a set threshold, inpatient nurses will be assigned to care for boarders in the emergency department, a practice sometimes called full capacity protocol, so that the burden of boarding is shared by the whole hospital and the staff strain loop is weakened.

Measuring the Effect and Watching for Side Effects

The hospitals will track boarding hours per admitted patient, the percentage of discharges before noon, diversion hours per month for the region as a whole, the share of patients leaving without being seen, emergency nurse turnover and length of stay for behavioral health patients. Systems thinking also calls for watching unintended consequences: earlier discharge could raise readmissions if patients leave before they are ready, so 30-day readmission rates will be monitored, and the capacity center could shift patients to the hospital with the most beds rather than the most appropriate one, so transfers will be reviewed monthly.

Conclusion

Emergency department boarding in the three hospitals is not an emergency department problem. It is produced by delayed discharges upstairs, uncoordinated diversion across the region, a shortage of behavioral health capacity and a staff strain loop that worsens everything. Solutions that addressed only the emergency department failed because they left those structures untouched. A solution that changes discharge timing, coordinates the region and creates behavioral health capacity targets the loops themselves and has a better chance of lasting.

References

Asplin, B. R., Magid, D. J., Rhodes, K. V., Solberg, L. I., Lurie, N., & Camargo, C. A. (2003). A conceptual model of emergency department crowding. Annals of Emergency Medicine, 42(2), 173-180. https://doi.org/10.1067/mem.2003.302

Boudi, Z., Lauque, D., Alsabri, M., Östlundh, L., Oneyji, C., Khalemsky, A., Lojo Rial, C., Liu, S. W., Camargo, C. A., Jr., Aburawi, E., Moeckel, M., Slagman, A., Christ, M., Singer, A., Tazarourte, K., Rathlev, N. K., Grossman, S. A., & Bellou, A. (2020). Association between boarding in the emergency department and in-hospital mortality: A systematic review. PLOS ONE, 15(4), e0231253. https://doi.org/10.1371/journal.pone.0231253

Peters, D. H. (2014). The application of systems thinking in health: Why use systems thinking? Health Research Policy and Systems, 12, 51. https://doi.org/10.1186/1478-4505-12-51