A woman in a wheelchair is parked against the wall, an elderly man lies on a gurney beneath a fire exit sign, and another patient waits on an ambulance stretcher because there is nowhere else to put him. Monitors beep over the din of conversations. Nurses weave between stretchers carrying medications and IV pumps. Physicians dart from one makeshift bedside to the next, delivering life-changing diagnoses in hallways with no curtains and little privacy. Every room in the emergency department is full. So are the halls. Upstairs, there are no beds to move patients into. The emergency department has become the hospital's waiting room.
Doctors in emergency departments across the country have long been aware of this ever-growing problem in which patients linger in the ED for days, weeks, or even months while waiting for an inpatient bed or transfer to another part of the hospital.
This issue started well before the pandemic and hasn’t improved much, said Jesse Pines, MD, clinical professor of emergency medicine at George Washington School of Medicine & Health Sciences in Washington, DC, and a spokesperson for the American College of Emergency Physicians (ACEP). “Boarding levels spiked in late 2021 and have remained relatively constant ever since.”
The reasons for these long stays in the ED range from rising ED volume and ongoing staffing shortages to unavailable inpatient beds. In addition, the average patient seeking care in the emergency department has more health issues than ever before, Pines added, complicating admissions.
“This is due to the aging of the population in general, but, also, the technology around medical care outside the ED is improving so dramatically that when people come into the ED they’re a whole lot sicker,” he said. “The broader health system can keep people alive that it couldn’t 20 years ago.”
No matter the reason, ED boarding negatively affects patients and care teams alike, and it means admitted patients spend a median 14 more minutes in the ED for every boarded patient, according to a recent study.
“Boarding is a major cause of a lot of negative things for ED staff,” Pines said. “It leads to workforce attrition and it’s one of the major causes of crowding and dysfunction in the emergency department. Patients are unhappy, and the staff is pulled in more directions and have to spend time with inpatients vs seeing new patients. It’s a terrible situation.”
Kimberly Chernoby, MD, an emergency medicine physician who works at four different ER systems in the Washington, DC, area, says there are boarded patients at every place she works, including one who boarded for over 20 days. She says most boarded patients are stuck in the ED because they have complicated health issues.
“Usually when the boarding times are in the multiple weeks, the patient is someone who has a psychiatric illness and needs inpatient admission,” said Chernoby. “Or they’re elderly with dementia, have a dual diagnosis, or might be violent.”
To deal with this issue, more staff is needed, Chernoby said. “The ED shouldn’t be treated like it has infinite capacity. There seems to be no regard for the fact that we see patients in hallways and chairs and our nurses can exceed safe nursing ratios but the same can’t be said upstairs.”
There’s a reliance on locum nurses, but this isn’t the only solution that should be tried, Chernoby said. “In fact, when nurses are unionized or in a state with a ratio cap, it becomes worse because there’s a cap for how many patients they will manage in the ED,” she added. “This means that they can’t bring patients back from the waiting room and then the waiting room backs up and becomes unsafe. Plus, it also means patients haven’t gotten any medication, labs, or screening tests like EKGs.”
In addition, hospitals need incentives to end this problem. “The big message is that boarding is a fixable problem if hospitals have the incentive to do so,” Pines said. “The current issue is that there’s very little incentive to really address boarding in a meaningful way because there are perverse economic incentives for hospitals to maximize bed use because elective admissions get more revenue than ED admissions. The result is that hospitals tend to try to maximize their elective admissions and use the ED for overflow. In the context of lower bed capacity, everything is overflowed into the ED.”
Despite all this, there are some innovative solutions happening around the country. For example, at Baptist Health-North Little Rock in Arkansas, hospital president Cody Walker leads a 225-bed hospital with a Level III trauma center and, under his leadership, Baptist Health launched Operation Raptor, a predictive capacity management initiative that leverages AI and advanced analytics to accelerate discharges, reduce ED boarding, optimize hospital capacity, and enable the system to care for more patients without adding beds or staff.
For example, to deal with the boarding crisis, Walker focused on operational efficiencies and predictive analytics. He likens it to the hotel experience.
“At a hotel, check in is at 3 PM and check out is at 11 AM,” he said. “But in healthcare it’s the opposite, and we made it a goal to unify doctors, nurses, and operational leaders to focus on those patients who can leave early in order to give that time back to other ED patients. If we stagger discharges and position them early in the day, that frees up patients’ rooms.”
So far, the hospital has experienced a 110% increase in 11 AM discharges. The team has also reduced the time that it takes from when a patient receives a discharge order to the time the patient remains in the same room, from 300 minutes to 170 minutes.
“When you cascade that across all discharges, that’s a dramatic reduction in overall boarding time that would be experienced by a patient,” he said. “And it reduces the worry a patient in a rural hospital feels when told that our ED is full.”
Using predictive analysis has been a game changer, too. “We’re looking 7 days ahead to where our choke points will occur,” he said. “We then stage staff weeks in advance as we predict patient volume, taking into account surgical cases, our historic trends, and what doctors and staff we have available on those days.”
Walker admits that there’s no way to perfectly gauge what might occur in an ED on a given day, but he says using predictive modeling helps the team plan as best they can.
“We’re leaning into those predictions,” he added. “By doing this, we can get closer to considering what’s going to happen on a particular day in our ED, and this makes the process of staffing smoother. It’s a culture change for all of us, but it’s working.”
Sources cited in this article had no relevant disclosures.
https://www.medscape.com/viewarticle/inside-growing-ed-boarding-crisis-2026a1000ovg
“This is due to the aging of the population in general, but, also, the technology around medical care outside the ED is improving so dramatically that when people come into the ED they’re a whole lot sicker,” he said. “The broader health system can keep people alive that it couldn’t 20 years ago.”
No matter the reason, ED boarding negatively affects patients and care teams alike, and it means admitted patients spend a median 14 more minutes in the ED for every boarded patient, according to a recent study.
“Boarding is a major cause of a lot of negative things for ED staff,” Pines said. “It leads to workforce attrition and it’s one of the major causes of crowding and dysfunction in the emergency department. Patients are unhappy, and the staff is pulled in more directions and have to spend time with inpatients vs seeing new patients. It’s a terrible situation.”
Kimberly Chernoby, MD, an emergency medicine physician who works at four different ER systems in the Washington, DC, area, says there are boarded patients at every place she works, including one who boarded for over 20 days. She says most boarded patients are stuck in the ED because they have complicated health issues.
“Usually when the boarding times are in the multiple weeks, the patient is someone who has a psychiatric illness and needs inpatient admission,” said Chernoby. “Or they’re elderly with dementia, have a dual diagnosis, or might be violent.”
To deal with this issue, more staff is needed, Chernoby said. “The ED shouldn’t be treated like it has infinite capacity. There seems to be no regard for the fact that we see patients in hallways and chairs and our nurses can exceed safe nursing ratios but the same can’t be said upstairs.”
There’s a reliance on locum nurses, but this isn’t the only solution that should be tried, Chernoby said. “In fact, when nurses are unionized or in a state with a ratio cap, it becomes worse because there’s a cap for how many patients they will manage in the ED,” she added. “This means that they can’t bring patients back from the waiting room and then the waiting room backs up and becomes unsafe. Plus, it also means patients haven’t gotten any medication, labs, or screening tests like EKGs.”
In addition, hospitals need incentives to end this problem. “The big message is that boarding is a fixable problem if hospitals have the incentive to do so,” Pines said. “The current issue is that there’s very little incentive to really address boarding in a meaningful way because there are perverse economic incentives for hospitals to maximize bed use because elective admissions get more revenue than ED admissions. The result is that hospitals tend to try to maximize their elective admissions and use the ED for overflow. In the context of lower bed capacity, everything is overflowed into the ED.”
Despite all this, there are some innovative solutions happening around the country. For example, at Baptist Health-North Little Rock in Arkansas, hospital president Cody Walker leads a 225-bed hospital with a Level III trauma center and, under his leadership, Baptist Health launched Operation Raptor, a predictive capacity management initiative that leverages AI and advanced analytics to accelerate discharges, reduce ED boarding, optimize hospital capacity, and enable the system to care for more patients without adding beds or staff.
For example, to deal with the boarding crisis, Walker focused on operational efficiencies and predictive analytics. He likens it to the hotel experience.
“At a hotel, check in is at 3 PM and check out is at 11 AM,” he said. “But in healthcare it’s the opposite, and we made it a goal to unify doctors, nurses, and operational leaders to focus on those patients who can leave early in order to give that time back to other ED patients. If we stagger discharges and position them early in the day, that frees up patients’ rooms.”
So far, the hospital has experienced a 110% increase in 11 AM discharges. The team has also reduced the time that it takes from when a patient receives a discharge order to the time the patient remains in the same room, from 300 minutes to 170 minutes.
“When you cascade that across all discharges, that’s a dramatic reduction in overall boarding time that would be experienced by a patient,” he said. “And it reduces the worry a patient in a rural hospital feels when told that our ED is full.”
Using predictive analysis has been a game changer, too. “We’re looking 7 days ahead to where our choke points will occur,” he said. “We then stage staff weeks in advance as we predict patient volume, taking into account surgical cases, our historic trends, and what doctors and staff we have available on those days.”
Walker admits that there’s no way to perfectly gauge what might occur in an ED on a given day, but he says using predictive modeling helps the team plan as best they can.
“We’re leaning into those predictions,” he added. “By doing this, we can get closer to considering what’s going to happen on a particular day in our ED, and this makes the process of staffing smoother. It’s a culture change for all of us, but it’s working.”
Sources cited in this article had no relevant disclosures.
https://www.medscape.com/viewarticle/inside-growing-ed-boarding-crisis-2026a1000ovg
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