Extended Time in ED Linked to Reported Racial Discrimination and Patient Dissatisfaction

There is an urgent need to address racial inequities and patient dissatisfaction associated with extended time in the emergency department (ED) as the health care system continues to face capacity challenges, new study findings suggest.¹

Despite these findings, the authors noted a paucity of interventions aimed at reducing racial and ethnic inequities in prolonged ED boarding.

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Investigators noted that boarding times in the ED have risen nationally,² but the implications for health equity have remained understudied. This study specifically aimed to investigate whether prolonged ED boarding contributed to increased perceived racial discrimination and dissatisfaction with care, with a particular focus on differences between patients from marginalized racial groups and non-Hispanic White patients.¹

Published in JAMA Network Open, the cross-sectional study conducted at a large urban hospital in Boston, Massachusetts, revealed associations between prolonged ED boarding and increased reports of racial discrimination and patient dissatisfaction. The study, which surveyed 525 patients between June 2023 and January 2024, highlights the potential for extended ED boarding to worsen health inequities, particularly for patients from marginalized racial and ethnic groups.

The investigators found that patients who boarded in the ED for 24 hours or more were more likely to report experiencing discrimination compared to those who boarded for less than 4 hours (OR, 1.84; 95% CI, 1.14-2.99; P = .01). Additionally, those with prolonged boarding times were more likely to express dissatisfaction with their care (OR, 1.77; 95% CI, 1.03-3.06; P = .04). These findings were even more pronounced among patients from marginalized racial and ethnic groups, who were more likely to report discrimination (OR, 2.36; 95% CI, 1.20-4.65; P = .01).

The study enrolled 525 patients admitted through the ED for internal medicine, with a balanced representation of non-Hispanic White patients (47.3%) and those from marginalized racial and ethnic groups (52.7%), including American Indian, Alaska Native, Hispanic, non-Hispanic Black, African American, and multiracial individuals. Of the participants, 57.1% were female, and the average age was 60.6 years. The patients were divided into 3 groups based on how long they boarded in the ED before being admitted: less than 4 hours, 4 to less than 24 hours, and 24 hours or more.

"Our results highlight 3 salient conclusions," investigators wrote. "First, prolonged ED boarding was common and associated with a threshold effect at 24 hours, at which point there was a significant increase in both perceived discrimination, particularly among patients from marginalized racial and ethnic groups, and dissatisfaction with care. Second, interactions with clinical staff may be an important factor underlying discrimination during ED boarding. Third, despite these findings, there remains a paucity of interventions aimed at reducing racial and ethnic inequities in prolonged ED boarding."

While the study did not find a significant effect modification between marginalized racial groups and non-Hispanic White patients in the association between boarding time and dissatisfaction, the increased perception of discrimination among marginalized groups points to a deeper issue that needs to be addressed.

"Increasing evidence suggests that racial discrimination and institutionally derived health inequities can be reduced or eliminated," the investigators concluded. "Successful methods include rewriting clinical guidelines with an equity lens, practitioner activation through timely reminders of institutional racism, and patient activation to short-circuit physicians’ implicit bias. Policy interventions at hospital, state, and federal levels are crucial for addressing the structural factors that contribute to discrimination and lower patient satisfaction during ED boarding."

References

1. Olson RM, Fleurant A, Beauparlant SG, et al. Prolonged boarding and racial discrimination and dissatisfaction among emergency department patients. JAMA Netw Open. 2024;7(9):e2433429. doi:10.1001/jamanetworkopen.2024.33429

2. Janke AT, Melnick ER, Venkatesh AK. Hospital occupancy and emergency department boarding during the COVID-19 pandemic. JAMA Netw Open. 2022;5(9):e2233964. doi:10.1001/jamanetworkopen.2022.33964