Emergency Department Boarding: A National Health Emergency
Tom Scaletta, MD FAAEM MAAEM
CEO/Auscura • Past President/AAEM • EP/Endeavor Health
Emergency department (ED) boarding occurs when admitted patients are in the ED for a prolonged time, awaiting a ready and staffed hospital bed. It starts when admission is requested and the patient no longer requires ED care, ending upon the patient’s departure from the ED. Boarding increases patient risk and severely disrupts ED operations.
Boarded ED patients receive suboptimal care because the ED team is trained to manage the initial hours of acute illness and trauma rather than the ongoing care of hospital inpatients. ED boarding leads to medication errors, treatment delays, and increased mortality for both admitted patients and new ED arrivals.[1],[2],[3],[4],[5],[6]
The COVID-19 pandemic accelerated the exodus of emergency and inpatient nurses, worsening ED boarding.[7] This crisis exposes systemic healthcare inefficiencies. ED boarding is a widespread, uncontrolled, and deadly national emergency—effectively, another pandemic.[8]
Extended waiting times in the ED, both before moving from the waiting room to the clinical area and while awaiting hospital admission, heighten patient frustration, anxiety, and feelings of neglect.[9] Privacy and dignity are compromised, particularly for those boarding in ED hallways and patients with behavioral health conditions. Patient satisfaction scores decline, while frontline ED staff face escalating verbal abuse, physical violence, and moral distress, contributing to high turnover rates. Professional liability and ethical dilemmas increase as clinicians navigate overcrowded conditions with limited resources.[10] Boarding also jeopardizes hospital financial stability by extending inpatient stays, delaying ICU-to-floor transfers, increasing operational costs, and limiting elective procedures.
Misconceptions persist regarding effective solutions to ED boarding. The presence of nearby urgent care centers and redirecting low-acuity patients after medical screening do not alleviate boarding, as these patients rarely require hospitalization. Similarly, diverting ambulances to less crowded hospitals is ineffective, as regional hospitals often face simultaneous capacity constraints, many admitted patients arrive independently, and most ambulance arrivals are ultimately discharged home.[11]
ED boarders represent the “inpatient waiting room.” Just as the ED manages its waiting area despite fluctuating volume and acuity, so should the inpatient team. Implementing "full capacity protocols” can help mitigate boarding by deploying additional staff, utilizing temporary units (e.g., pre-/post-operative areas), and accommodating patients in inpatient hallways. However, the crisis is evident when such emergency measures become standard practice.
Critical low-wage roles, such as ED-to-floor transporters and inpatient housekeepers, must be redundantly staffed to prevent bottlenecks. Inpatient hallway boarding should be standard practice when rooms are vacant but awaiting cleaning. "Surgical smoothing," which distributes elective procedures evenly throughout the week, helps prevent sudden admission surges. Maintaining hospital occupancy below 90% is essential to avoid inpatient gridlock, and an impartial "bed boss" should oversee bed assignments, expedite admissions, and optimize efficiency.[12]
Reducing unnecessary admissions offers the most effective strategy to minimize ED boarding and control global healthcare costs. While approximately 30% of adult ED patients require hospitalization, admission rates vary between 20% and 40% due to practice variation and individual "tolerance of uncertainty." Identifying high admitters and providing targeted coaching can help reduce admission rates. ED case management teams are crucial in lowering admissions by ensuring timely outpatient follow-up and facilitating alternatives such as direct ED-to-SNF transfers.
Regulatory agencies and policymakers must be more proactive in addressing ED boarding. While The Joint Commission (TJC) recognizes the dangers of ED boarding, it has not established accreditation requirements. Instead, hospitals are left to define and implement their own boarding management goals.[13]
The Leapfrog Group (TLG), a nonprofit dedicated to healthcare quality, has introduced new hospital safety requirements, including ED boarding metrics. Hospitals must report the percentage of admitted ED patients, including those under observation status, who experience boarding times exceeding four hours, along with the 50th and 90th percentile lengths of stay for admitted patients.[14]
State and federal regulations are essential to prioritizing ED admissions and preventing harmful delays, yet no laws currently regulate ED boarding.[15] In 2023, the Centers for Medicare & Medicaid Services proposed a quality measure for ED boarding beyond four hours, though it remains uncertain whether compliance will be mandated, publicly reported, or tied to financial incentives.[16] In 2024, the Agency for Healthcare Research and Quality convened a conference on ED boarding, indicating interest in supporting research and potential funding initiatives.[17]
Some states have implemented proactive measures to address ED boarding. Maryland leads this effort by integrating ED boarding into its Quality-Based Reimbursement (QBR) program for 2026, linking 2% of hospital revenue to performance metrics.[18] Connecticut established the ED Boarding and Crowding Working Group to develop targeted solutions, while California is pursuing mandatory hospital reporting on ED boarding times.[19] Additionally, other states have initiated public-private partnerships to mitigate ED boarding through enhanced community resources, expanded outpatient services, and improved care coordination.
In conclusion, ED boarding is a critical indicator of a healthcare system in crisis. Addressing this issue requires hospital and policy-level interventions, including capacity management, discharge optimization, and sustainable staffing strategies. System-wide collaboration and regulatory action are essential to protecting patient safety, supporting healthcare professionals, and maintaining financial stability.
[1] Jones et al., 2022 – Emergency Medicine Journal (Original Research): “Association between delays to patient admission from the emergency department and all-cause 30-day mortality.” Emerg Med J. 39(3): 168-173 (2022). DOI: 10.1136/emermed-2021-211572.
[2] Boudi et al., 2020 – PLOS ONE (Systematic Review): “Association between boarding in the emergency department and in-hospital mortality: A systematic review.” PLOS ONE 15(4): e0231253 (2020). DOI: 10.1371/journal.pone.0231253.
[3] Roussel et al., 2023 – JAMA Internal Medicine (Original Research): “Overnight stay in the emergency department and mortality in older patients.” JAMA Intern Med. 183(12): 1378-1385 (2023). DOI: 10.1001/jamainternmed.2023.5961.
[4] Mohr et al., 2020 – Critical Care Medicine (Review/Task Force Report): “Boarding of critically ill patients in the Emergency Department.” Crit Care Med. 48(8): 1180-1187 (2020). DOI: 10.1097/CCM.0000000000004385.
[5] Rocha et al., 2021 – Journal of Nursing Scholarship (Systematic Review): “Adverse events in emergency department boarding: a systematic review.” J Nurs Scholarsh. 53(4): 458-467 (2021). DOI: 10.1111/jnu.12653.
[6] Joseph et al., 2024 – JAMA Network Open (Original Research): “Boarding Duration in the Emergency Department and Inpatient Delirium and Severe Agitation.” JAMA Netw Open. 7(6): e2416343 (2024). DOI: 10.1001/jamanetworkopen.2024.16343.
[7] Kilaru et al., 2023 – Annals of Emergency Medicine (Original Research): “Boarding in US Academic Emergency Departments During the COVID-19 Pandemic.” Ann Emerg Med. 82(3): 247-254 (2023). DOI: 10.1016/j.annemergmed.2022.12.004.
[8] Kelen et al., 2021 – NEJM Catalyst (Commentary): “Emergency Department Crowding: The Canary in the Health Care System.” NEJM Catalyst 2(5): (Sept 2021). DOI: 10.1056/CAT.21.0217.
[9] Kanzaria, H. K., Probst, M. A., Hsia, R. Y., Moriates, C., & McNamara, M. (2021). Emergency department wait times, inpatient experiences, and patient satisfaction: Implications for hospital reimbursement. Journal of Patient Experience, 8, 1-6. https://doi.org/10.1177/23743735211025001
[10] Rodriguez, M. (2022, September 30). Emergency department crowding hits crisis levels, risking patient safety. Yale News. https://news.yale.edu/2022/09/30/emergency-department-crowding-hits-crisis-levels-risking-patient-safety
[11] Kao, C.-Y., Yang, J.-C., & Lin, C.-H. (2015). The impact of ambulance and patient diversion on crowdedness of multiple emergency departments in a region. PLOS ONE, 10(12), e0144227. https://doi.org/10.1371/journal.pone.0144227
[12] Janke et al., 2022 – JAMA Network Open (Original Research): “Hospital occupancy and emergency department boarding during the COVID-19 pandemic.” JAMA Netw Open 5(9): e2233964 (2022). DOI: 10.1001/jamanetworkopen.2022.33964. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2796859
[13] The Joint Commission. (2023). ED boarding: Impact on patient care and clinician well-being. Retrieved 3/17/25 from https://www.jointcommission.org/resources/news-and-multimedia/news/2023/11/ed-boarding-impact-on-patient-care-and-clinician-well-being/
[14] The Leapfrog Group. (2025). Leapfrog hospital survey: Summary of changes 2025 (Section 6E). Retrieved 3/17/25 from https://www.leapfroggroup.org/sites/default/files/Files/Leapfrog%20Hospital%20Survey_Summary%20of%20Changes_2025_Final.pdf
[15] Moore, C., & Heckmann, R. (2025, March 12). Hospital boarding in the ED: Federal, state, and other approaches. Health Affairs Forefront. https://doi.org/10.1377/forefront.20250310.355985
[16] Centers for Medicare & Medicaid Services. (2023). Median Admit Decision Time to ED Departure Time for Admitted Patients (CMS111v11). eCQI Resource Center. https://ecqi.healthit.gov/ecqm/eh/2023/cms0111v11
[17] U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2024, March 17). Notice of interest: Emergency department boarding research funding opportunity. National Institutes of Health. Retrieved from https://grants.nih.gov/grants/guide/notice-files/NOT-HS-25-012.html
[18] Health Services Cost Review Commission. (2023). Quality-Based Reimbursement (QBR) Program: Recommendations for Rate Year 2026. Retrieved from https://hscrc.maryland.gov/Documents/Quality_Documents/QBR/RY2026/RY26%20Final%20QBR%20Recommendation.pdf
[19] Connecticut General Assembly. (2024). Public Act No. 24-4: An Act Concerning Emergency Department Crowding. Retrieved from https://www.cga.ct.gov/2024/act/pa/pdf/2024PA-00004-R00SB-00181-PA.pdf
Dedicated Health Care Leader | Combining Nursing Expertise & Strategy to Advance Patient And Operational Outcomes
5moThank you for offering insight regarding the true root(s) of leading to ED boarding. Boarding negatively impacts patient safety and satisfaction as well as that of nurses and providers. Preventing unnecessary ED visits, mitigating readmissions and standardizing throughput processes will not fix all issues resulting in ED boarding, but it is a start.
Retired
5moJoint Commission won’t ever mandate this as every ER in the U.S. would close all at the same time. They don’t want to be responsible
Maggie is dedicated to being a tireless champion for nurses. She strives to protect nurses' rights and elevate the nursing profession as a whole.
5moWhere to begin with this…. And nurses are the ones left to manage this mess more often than not and let’s remeber that ER nurse are NOT inpatient nurses. Going to get worse as home health and SNF patient discharged due to loss of insurance and will be needing admission for care. Let’s remember patients come to the hospital for skilled nursing Hare. If they need a doctor care they would be at home. Let’s remember that again patients come to the hospital because they need nursing care not doctor care.
Advocate For Nurses Experiencing Actions Against Their License
5moThis issue was researched under the URGENT MATTERS multi-facility study conducted by the Robert Wood Johnson Foundation. We arrived at some solutions. Emergency department (ED) throughput showed improvement for several years in the early 2000s, but with the current surge in inpatient holds, the problem has resurfaced. At our County Level I trauma center, we implemented significant changes. We already staffed the PACU 24/7, allowing us to board at least two inpatients there. Additionally, we initiated EMS diversion—a major decision given that we are the only Level I trauma center serving 26 counties. To expedite discharges, chief residents and faculty conducted rounds twice daily. Elective surgeries requiring inpatient beds were even canceled when necessary. These measures placed considerable pressure on those responsible for timely inpatient discharges, ensuring beds were freed up as quickly as possible. No one wanted the trauma surgery team frustrated over excessive ER holds forcing diversion, which compromised our ability to safely resuscitate critical patients. Moreover, the hospital had a vested interest in maintaining its revenue from elective surgeries, which motivated leadership to unblock beds and increase staffing.
Locum ER physcian at Grey Bruce Health Services
5moThere is so much evidence that ER boarding of inpatients instead of transferring them to the inpatient unit costs lives that it boggles my mind that admin still allows it to occur. I’ve seen it first hand in many ERs. ER nurses have a different approach, mindset and skill set than inpatient nurses. Even in the rural hospitals that I work at where nurses may float to the other units, the ER nurses arenalways ER nurses. And they are trying to balance the chaos of the ER with the needs for routine of the inpatient. Why can’t we get this message respected even with good science to back us!