Emergency department boarding is a longstanding and urgent challenge affecting hospitals across the country. The issue has far-reaching consequences that negatively affect care quality, clinician well-being and increase costs for health systems.
With many hospitals operating near or above capacity, addressing ED boarding has reemerged as top priority to improve patient throughput and operational efficiency in 2024.
Here are 10 things to know about the prevalence of ED boarding and complex factors driving the issue nationwide:
The scope and cost of the problem
- ED boarding refers to the practice of holding patients in the ED, often in hallways, when they require admission but no inpatient beds are available. The Joint Commission considers boarding a patient safety risk and recommends it not exceed four hours. However, the majority of ED physicians say they have experienced boarding times in their facilities exceeding 24 hours.
- While not a new problem, ED boarding reached crisis levels during the COVID-19 pandemic due to staffing shortages, clinician burnout and increased demand for hospital services. In fall 2022, dozens of medical groups – including the American Medical Association and American Nurses Association – wrote a letter to President Joe Biden, saying boarding had reached a "crisis point." The groups underscored patient safety and quality risks associated with boarding, such as care delays and in some cases, death.
- Average ED boarding times fell from 182 minutes in 2022 to 110 in 2023, though it remains a significant challenge for high-volume departments, according to a report from the Emergency Department Benchmarking Alliance. In some cases, patients in need of hospital level care are held in ED beds that lack the same space and functionality as inpatient units for days, as many emergency physicians described in their letter to the White House. Many emergency physicians have reported that boarding numbers frequently approach or exceed the total number of beds in their EDs.
"Our 40 bed ED was boarding a large number of patients up to several days awaiting an inpatient hospital bed with a waiting room of [more than] 30 people," one physician wrote.
- Nearly half of Americans say they would delay or avoid emergency care due to concerns about extended ED stays, according to a 2023 survey conducted by the American College of Emergency Physicians. The survey findings suggest personal experience with boarding and long wait times has an influence on patients' willingness to seek emergency care. Forty percent of respondents said they or a loved one have experienced long ED wait times.
- In addition to patient safety risks, boarding carries steep financial implications for health systems. In 2024, at least two health systems — Portland-based Oregon Health & Sciences University and San Diego-based Scripps Health — linked financial challenges to ED overcrowding.
A study published the same year found the daily cost of boarding patients in the ED is nearly double that of inpatient care, driven by higher staffing costs and inefficient use of resources. For example, the daily cost for medical/surgical boarding was $1,856, compared to $993 for inpatient care, with the gap widening to $2,258 versus $1,095 when factoring in travel nurse expenses. Led by researchers at UMass Chan Medical School and UMass Memorial Health in Worcester, Mass., it was one of the first peer-reviewed studies to comprehensively assess financial ramifications tied to boarding.
- Boarding exacerbates burnout among healthcare workers, with clinicians indicating the issue prevents them from delivering proper care and exposes them to higher rates of verbal and physical abuse from frustrated patients, according to a research published in The Joint Commission Journal on Quality and Patient Safety.
Primary drivers
- A variety of overlapping factors contribute to persistent boarding and capacity issues at hospitals, with one consistently at the forefront: a lack of space in nursing homes and other long-term care facilities. As such, hospitals often face delays in discharging patients who no longer need inpatient care but cannot be placed in post-acute facilities.
At Scripps Health, nearly 35,000 patients remain hospitalized annually even though they are ready to be discharged, due to challenges securing post-acute care placements. This tally has risen more than 100% in three years, creating significant financial and operational pressures. The system transferred obstetric services from Scripps Mercy Hospital Chula Vista to its San Diego campus, in part due to boarding challenges at its Chula Vista facility.
Behavioral health patients often bear the brunt of ED boarding, facing some of the longest wait times due to a chronic lack of access to appropriate mental health care settings. One physician shared an account with ACEP of a teenage patient who spent more than 40 days in an ED room awaiting transfer to an inpatient psychiatric facility.
- In their letter to the White House, major healthcare industry groups also described "misaligned incentives" as a driver of ED boarding. Stories about health systems prioritizing more lucrative elective admissions for surgeries over ED admissions were a common theme among emergency medicine clinicians who participated in an ACEP poll.
"We are a top nationally ranked hospital that, due to budget issues, has now prioritized transfers and surgery admissions over ED admissions," one physician wrote at the time, adding the facility typically boards 120 to 200 hours per day.
In some cases, however, health systems have had to divert patients with scheduled surgeries or those seeking specialty care elsewhere due to the rising number of emergency department admissions. At OHSU, for example, around 40% of admissions are from the ED, a significant increase over five years.
The path forward
- In December 2023, HHS tasked the Agency for Healthcare Research and Quality with convening a multistakeholder roundtable to identify next steps and novel opportunities to address overcrowding and boarding in EDs, which was held in October 2024. At the summit, stakeholders from hospitals, regulatory agencies and lawmakers gathered to discuss ways to ease capacity issues, such as establishing structured frameworks to measure the issue, align payment structures and incentives, and ways to engage community health centers in care coordination. The federal agency plans to publish a report detailing action items in the coming months.
ACEP has also urged CMS to update its Condition of Participation for emergency services, requiring hospitals to implement response plans when boarding surpasses certain thresholds. - As hospitals await national, system-level solutions to take shape, many are implementing innovative measures to navigate ED boarding.
In October, Hollywood, Fla.-based Memorial Healthcare opened a centralized care coordination center to optimize bed capacity across its six acute-care facilities. The center operates as a 24/7 clinical command hub, coordinating interfacility transfers, bed placement, float pool staffing and virtual care models. The facility is equipped with data dashboards that provide real-time views of capacity and patient flow, which enable staff to quickly identify open beds and minimize discharge delays.
More broadly, health system leaders are prioritizing structures and processes to improve length of stay and thus, mitigate boarding. In October, Erik Summers, MD, highlighted a strategy that he ascribed to significant reductions in length stay: Empowering and elevating care coordination teams to play a central role in patient discharge.
"There are a lot of factors that can affect length of stay, but the number one opportunity in my opinion nationwide is the development and support of your case management or care coordination team," he previously told Becker's. Dr. Summers is the chief medical officer of MUSC Health's Charleston, S.C., division. He previously served as CMO of Atrium Health Wake Forest Baptist Medical Center in Winston-Salem, N.C.