Many ED hallways are filled with patients who have been admitted, but cannot move out of the department because no inpatient bed is available.

“There is a tendency to think of boarding as an ‘ED problem.’ But the whole system needs to be looked at. It has to come from the top. The CEO has to do what needs to be done to streamline the process,” says Robert W. Derlet, MD, professor emeritus at the UC Davis Health department of emergency medicine.

Often, says Derlet, “the ED leadership, the nursing director, and physician director, say, ‘We’ve got a problem here.’ Too many hospital CEOs say, ‘It’s your problem.’”

ED providers cannot simply contact the inpatient unit to try to speed things up since they do not know for sure where the ED patient is going. “It’s getting that assigned bed that’s critical,” Derlet notes.

Since hospitals rely on elective surgeries for financial viability, patients admitted from the ED tend to be a somewhat lower priority. Asking hospital administrators to observe the risks of ED boarding firsthand can help change this perception.

“They don’t know what it’s like on the front lines. Have them spend a shift in the ED, either Friday or Saturday night,” Derlet recommends. A one-time “snapshot” of a dangerously crowded ED with hallways full of patients is not nearly enough to really understand this pervasive problem. To truly grasp the reality of ED boarding, says Derlet, “CEOs, who hold the purse strings, need to spend an hour a day in the ED one or two days every week, for several weeks.”

Otherwise, hospital leaders may remain largely unaware of the risks when ED patients are cared for in hallways. “Hallway care is fraught with disaster,” Derlet observes.

Issues can arise regarding monitoring in crowded hallways, the fact oxygen tanks have to be used, total lack of privacy, and ED providers bumping into each other while examining patients. Derlet recommends a few practices to mitigate risks when EDs are crowded, and patients are boarded in hallways:

  • EDs need to take whatever measures are possible to avoid waits at triage. “There should never really be a line for triage. Somebody may have a very serious condition, and 15 minutes could be the difference between life and death,” Derlet stresses.
  • Triage nurses need to remember to use their best clinical judgment in determining acuity. Derlet cautions against overdependence on computer algorithms.
  • Triage nurses need to communicate with the EPs on anything they are unsure about. “Unfortunately, in some EDs, there is a wall between the triage nurse and the emergency physicians, and they don’t talk too much,” Derlet laments.

ED boarding “threatens safety, and increases malpractice risks,” Derlet adds. “I have seen increasing lawsuits being filed because of poor outcomes as a result of ED crowding.”

Gelareh Gabayan, MD, an associate professor of medicine/emergency medicine at UCLA, says the problem of ED boarding could be solved by simply moving the patient upstairs, regardless of whether a bed is available.

“If the patient is able to stay in a hallway downstairs, then they are able to stay in the hallway upstairs. I promise you they won’t; everyone would find a way to get the patients out faster,” Gabayan offers.

Any ED visit is a high-stress situation for both patients and providers, Gabayan notes. “Why add to the pressure by boarding patients in hallways, and not leaving any room for the patients who need to be seen?”