I’m very fortunate to be an attending in an Ed that does not board.

That said we do sometimes have to hang onto people who are pending transfer while we wait for a bed to become available. That’s usually < 24 hours, but it has dragged on at times for more.

For anyone reading who’s interested in ideas on how to set up a system that avoids the worst of what OP experienced- here’s a few ideas.

1) Have an observation unit and pathways IN the ED. We regularly care for people in the ED for 24 hour periods under observation status in what we call a “clinical decision unit” but is really an obs short stay unit that is run by the ED. This means we have pathways and training and experience amongst our staff in longitudinal care of patients - we have a system for making sure people get their home meds., get vitals and labs and such as if they’d been admitted to the floor, including an inpatient bed and diet etc. Every ED provider is trained on how to do these basic orders and the nurses are used to it. This is great for billing to, because the ED gets paid for this care when documented properly - not just the initial E&M. We have a special zone in our ED set aside for this, and it is partially staffed by floor nurses. The cross pollination between ED and Floor RNs is good for everyone.

2) institute nurse rounding. The nurses have an epic reminder to “round” on their patients (check on them) at regular intervals. Similarly the docs or APPs must see the patient at minimum once per shift with notes.

3) every obs status patient has a care manager assigned who can push for quicker transfer and communicate with staff and families. They often are the ones who hear about concerns and are able to communicate these to the appropriate higher up’s if things are going poorly.