Emergency department boarding: Covering the hidden horror story

Emergency department boarding is a horror story that's largely hidden from public view.

Very sick patients are held for hours or even days in the emergency department, often on a gurney in a hallway, waiting for an inpatient bed or transfer to another facility. As appropriate care is delayed, they experience avoidable pain and complications.

Emergency department boarding has worsened in recent years, experts say, as hospitals face greater financial pressure to wring out excess inpatient capacity and prioritize beds for lucrative scheduled procedures, such as surgeries and cancer treatment.

For that reason, emergency department boarding is an important and timely patient safety story. However, it may not be easy to cover.

Hospitals aren't required to disclose if and when they board patients, and some hospital administrators are reluctant to discuss the problem publicly.

This tip sheet provides resources for digging into the topic and key concepts to include in your coverage. You can learn a lot by watching a two-part video of a boarding summit convened in October by the HHS Agency for Health Quality and Research.

Points to underscore in your coverage

1. Boarding is not caused by misuse of the emergency department. The emergency room can usually manage patients with minor problems like sprains and flu-like symptoms. Rather, the core problem is a shortage of inpatient beds for patients who need to be admitted due to conditions such as pneumonia, congestive heart failure, and stroke.

1. Boarding reflects health care system failures. Experts point to payment incentives that encourage hospitals to operate at or over capacity and deprioritize patients admitted via the emergency department. And when patients are ready for discharge, hospitals may have difficulty placing them in specialized care such as skilled nursing or inpatient rehab. Some patients get trapped in the emergency department due to a shortage of psychiatric beds.

1. Harms are apparent. Patient harms associated with boarding included missed or delayed treatments and tests, longer lengths of stay, higher complication rates, delirium and medication errors. A 2023 study in France linked overnight emergency department stays to higher mortality for older patients, although a previous literature review concluded that more research is needed to establish a clearer connection between boarding and mortality. Boarding has been linked to higher hospitalization costs and higher costs for stroke care.

1. Boarding can be fixed, if incentives are in place. Hospitals have implemented successful strategies to alleviate boarding including surgical smoothing to schedule surgeries over more days of the week, creating observation units, and appointing bed czars to identify patients who can be discharged or released from an ICU. However, advocates say federal policymakers will have to realign hospitals' financial incentives to make sufficient beds available.
2. Accountability is lacking. The Joint Commission, a hospital accrediting body, has declared boarding to be a safety risk that should not exceed four hours, but experts say the organization doesn't enforce its own standard. Meanwhile, the federal government has no hospital quality measure for boarding; CMS retired a voluntary measure but has not enacted a proposed replacement. The American College of Emergency Physicians (ACEP) has proposed steps such as mandating information-sharing on bed availability, measuring hospital performance using a specific time standard, and requiring hospitals to develop and implement boarding response plans.

Story ideas

• Ask hospitals what they're doing to reduce boarding. Some hospitals such as Memorial Healthcare System in Hollywood, Fla., and Massachusetts General Hospital in Boston have gone public with their strategies. Ask independent experts whether these steps are likely to have a significant impact.
• Report on state efforts to manage capacity. For example, the Oregon Capacity System tracks real-time census data from every hospital in the state. Massachusetts health authorities called on providers and health plans to take steps to free up capacity.
• Tell patient stories. The Portland Press Herald's Joe Lawlor wrote about a 13-year-old girl in Maine who lived in an emergency department for 304 days, waiting for a spot in an intermediate care facility for people with intellectual disabilities.
• Explore the impact on older patients. Judith Graham wrote a piece for KFF Health News explaining how boarding disproportionately harms seniors. It provided expert advice for patients and their families to get through a boarding episode. You can examine the impact of a new federal Age-Friendly Hospital Measure, which calls for moving older patients out of the emergency department within eight hours of arrival or three hours of a decision to admit.
• Emergency room crowding has ripple effects. Long wait times prompt patients to leave without being seen and consume the time of emergency responders. KING 5 television news in Seattle reported about firefighters who were called to help out in a hospital emergency department that was overwhelmed.

• Overcapacity is a national security issue. A 2016 paper determined that 86% of U.S. regions at high risk of terrorist attacks had high boarding times, as did 36% of regions with frequent natural disasters. Boarding appears to be even more common now. "We have a total mismatch between a system that is running at 110% capacity and an expectation that we can save American lives when the unthinkable happens," Brendan Carr, M.D., an emergency department physician and chief executive officer of Mount Sinai Health System in New York, said during the summit.
• Boarding contributes to violence and clinician burnout. A 2023 survey of emergency room clinicians reported that boarding contributes to perceptions of burnout and verbal and/or physical abuse by boarding patients.

Sources

ACEP has spearheaded efforts to draw attention to emergency department boarding. The group maintains a web page on emergency boarding and crowding and can put you in touch with members of its state chapters who can discuss local capacity. The Emergency Nurses Association and the National Association of EMS Physicians also have members who are greatly affected by boarding.

Documents and reports

• ACEP letter to the White House - a 2022 letter signed by 35 organizations requesting federal attention be focused on ER boarding.
• Emergency Rooms Shouldn't Be Parking Lots For Patients - a NPR opinion piece about the financial incentives that lead boarding.
• A Nation in Crisis: Real Stories from the Frontline - an ACEP collection of more than 100 stories from emergency department physicians.
• Boarding of Critically Ill Patients in the Emergency Department - a 2020 review paper that concludes boarding is common for patients with life-threatening injuries or illnesses.
• Emergency department and hospital crowding: causes, consequences, and cures - a 2019 paper that provides an overview.
• Boarding Duration in the Emergency Department and Inpatient Delirium and Severe Agitation - a 2024 JAMA article.