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Alarm Raised Over Patient Boarding in Emergency Departments

Analysis  |  By Christopher Cheney  
   November 14, 2022

The group representing emergency physicians and other healthcare organizations say emergency department boarding has reached "a breaking point."

The American College of Emergency Physicians (ACEP) and 34 other healthcare organizations are urging the Biden administration to hold a summit to address crisis levels of patient boarding in emergency departments.

Boarding in emergency departments occurs when there is a shortage of inpatient beds for hospital admissions or there are no beds at external facilities such as psychiatric hospitals. The Joint Commission recommends that emergency department boarding not exceed four hours; however, it has become common to have emergency department boarding for days or weeks, according to ACEP.

In a letter sent last week to President Biden, ACEP and three dozen other healthcare organizations paint a grim picture of the adverse impacts of emergency department boarding.

"In recent months, hospital emergency departments (EDs) have been brought to a breaking point. Not from a novel problem—rather, from a decades-long, unresolved problem known as patient 'boarding,' where admitted patients are held in the ED when there are no inpatient beds available. While the causes of ED boarding are multifactorial, unprecedented and rising staffing shortages throughout the healthcare system have recently brought this issue to a crisis point, further spiraling the stress and burnout driving the current exodus of excellent physicians, nurses and other healthcare professionals," the letter says.

The letter details five negative effects of emergency department boarding:

1. Patient harm: "There is ample evidence that boarding harms patients and leads to worse outcomes, compromises to patient privacy, increases in medical errors, detrimental delays in care, and increased mortality," the letter says.

2. Providing care in waiting rooms: "Many emergency physicians who submitted stories reported daily numbers of boarders close to or even exceeding 100 percent of the total number of beds in their EDs, while the number of patients in the waiting room comprised up to 20 times the number of free treatment beds in which they could even be seen. In the past, that often left only hallway stretchers within the ED to care for incoming patients. But now, those too are increasingly over capacity, and so the emergency department waiting room has become the latest ad-hoc location for receiving patient care," the letter says.

3. Pediatric patients: "Unfortunately, the pediatric population is not immune to the serious ED boarding issue we are facing—particularly those with mental health conditions. During the last decade, pediatric ED visits for mental health conditions have risen dramatically. The COVID-19 pandemic led to a greater acceleration of these visits, causing several pediatric health organizations to issue a national emergency for children's mental health in 2021 and the U.S. Surgeon General to release an advisory on mental health among youth. … Multiple studies show that pediatric patients with mental health conditions who are boarded are more likely to leave without being treated, and less likely to receive counseling or psychiatric medications," the letter says.

4. Psychiatric patients: "Boarding of psychiatric patients in EDs is particularly prevalent, disproportionately affecting patients with behavioral health needs who wait on average three times longer than medical patients because of significant gaps in our healthcare system. While the ED is the critical frontline safety net, it is not ideal for long-term treatment of mental and behavioral health needs. Research has shown that 75 percent of psychiatric emergency patients, if promptly evaluated and treated in an appropriate location—away from the active and disruptive ED setting—have their symptoms resolve to the point they can be discharged in less than 24 hours. However, far too many Americans have limited options for accessing outpatient mental health care," the letter says.

5. Boarding drives burnout: "Overcrowding and boarding in the emergency department is a significant and ever-growing contributor to physician and nurse burnout, as they must watch patients unnecessarily decompensate or die despite their best efforts to keep up with the growing flood of sicker and sicker patients coming in. Healthcare professionals experiencing burnout have a much higher tendency to retire early or stop practicing all together. This increases the loss of skilled healthcare professionals in the workforce and adds more strain to those still practicing, which continues the cycle of burnout within the profession," the letter says.

Related: Researcher: 'The Levees Have Broken' at Emergency Departments

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


Emergency department boarding has been linked to patient harm, including medical errors, delays in care, and increased mortality.

In some cases, emergency department boarding has made it necessary to provide care in waiting rooms.

Emergency department boarding disproportionately impacts psychiatric patients because there is a shortage of outpatient and inpatient psychiatric care.

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