Boarding critically ill patients in EDs is associated with worse clinical outcomes, according to the authors of a recently published white paper.1

“Boarding in EDs occurs because the hospital beds are full. Patients are the ones who suffer,” says Nicholas Mohr, MD, FACEP, FCCM, co-chair of the ED-Critical Care Medicine (ED-CCM) Boarding Task Force that authored the paper and former chair of the American College of Emergency Physicians’ Critical Care Section.

As hospital capacity is stretched, patients wait in ED beds for hours or days until a bed finally becomes available. “ED boarding has increasingly been shown to be dangerous for patients who are critically ill,” says Mohr, a professor of emergency medicine, anesthesia critical care, and epidemiology at the University of Iowa Carver College of Medicine.

The task force found ED boarding is linked to longer duration of mechanical ventilation, higher mortality, and longer length of stay (both in the ICU and the hospital overall). Some findings from studies that were included in the literature review:

  • Longer boarding times are associated with deteriorated organ dysfunction and make it more likely stroke patients experience poor neurologic recovery.
  • Boarding can cause low-quality process-related care of critically ill patients who waiting to be admitted to the ICU. Emergency medicine critical care (EMCC) is a relatively new subspecialty, concerning the care of critically ill patients in the ED and other settings.

“We get to see the downstream impact of ED care on the critically ill,” says Brian T. Wessman, MD, FACEP, FCCM, co-chair of the ED-CCM Task Force.

Initial ED care includes mechanical ventilator set-up and management, sedation, timely administration of antimicrobials, and ongoing decisions regarding type and amount of fluid resuscitation. “We have data showing that a large majority of initial ED care impacts downstream patient management and outcomes,” says Wessman, division chief of emergency medicine/critical care medicine at Washington University’s School of Medicine in St. Louis.

Improving hospital throughput means critically ill patients are not stuck in EDs waiting for ICU beds. “No matter where critically ill patients are, though, they need the same intensity of care to have the best outcomes,” Mohr says.

Some hospitals have found a novel solution in the form of resuscitative care units (RCUs), which are ICUs based in EDs.2 Approaches vary, but the basic concept is patients who need time-sensitive respiratory, metabolic, neurologic, or hemodynamic critical care can receive it in the ED. This prevents these patients from waiting so long for a bed to finally open in the appropriate specialty ICU.

“Regardless of physical location, critically ill patients need similar resources,” Wessman notes.

Critically ill patients need ICU-level nursing in an appropriate patient ratio, access to supplies, continuous monitoring, and available physicians who are directly providing their care. “By definition, this will be difficult in an already-taxed ED location that is continuing to provide appropriate care and stabilization to newly arriving patients — unless the system allocates more resources and support,” Wessman explains.

The ED-CCM Boarding Task Force found it was surprisingly hard to measure the prevalence of boarding. “Even though we think it’s common, there’s no standard way that it’s measured or reported from hospitals across the country,” says Mohr, noting that makes it hard to track changes over time.

Additionally, the task force found no uniform definition of ED boarding. “This is an underrepresented and underreported issue,” Wessman says.

Researchers used all kinds of different definitions and time frames in examining ED boarding. Some studies categorized the admitted patient as “boarded” only if the patient spent a certain amount of time in the ED. Other studies counted the total amount of time spent in the ED as the “boarded” period. Still other researchers used the time frame that elapsed only after the decision to admit was made.

Regardless of the exact criteria used, the overall implications are clear. “Managing critically ill patients in the austere environment of the ED with limited support/resources makes it difficult to provide critical care,” Wessman stresses.

A recent review of 12 studies did not reveal clear evidence of a link between ED boarding and in-hospital mortality.3 Six studies indicated an association, five studies showed none, and one study produced conflicting results. One limitation was that the various studies used different time frames.

“The problem is that there were many different cutoffs used. It was not possible to deeply study the relationship,” says Abdelouahab Bellou, MD, MSc, PhD, one of the study’s authors.

More research is needed to determine if there is a specific time cutoff linked to higher in-hospital mortality. “We need a very big study, using the same definition and the same population,” says Bellou, director of quality and safety, administration and leadership, and international emergency medicine fellowship at Harvard.

The inconclusive finding conflicted with the researchers’ clinical experience in the ED. “We are not happy when our patients are staying in the ED for many, many hours,” Bellou says. “We have this feeling we are not doing a good job for the patient. But feeling is not science.”


  1. Mohr NM, Wessman BT, Bassin B, et al. Boarding of critically ill patients in the emergency department. Crit Care Med 2020;48:1180-1187.
  2. Wessman BT, Mohr NM. Emergency department ICUs add value. Crit Care Med 2020; Oct 26. doi: 10.1097/CCM.0000000000004708. [Online ahead of print].
  3. Boudi Z, Lauque D, Alsabri M, et al. Association between boarding in the emergency department and in-hospital mortality: A systematic review. PLoS One 2020;15:e0231253.