When ED boarding times of non-trauma patients were longer, trauma patients also stayed in the ED longer, according to a recent analysis.1

For every additional 10 minutes that non-trauma patients were boarded in the ED, the median length of stay for trauma patients extended by 7.8 minutes. This finding came as no surprise to researchers.

“We were living this every day. The study effectively confirmed what we already knew,” says David Ledrick, MD, associate residency director and clinical clerkship director in the department of emergency medicine at Mercy St. Vincent Medical Center in Toledo, OH.

Ledrick and colleagues knew their ED was not the only department with this issue. “We wanted to offer other EDs with similar problems some insight in approaching them,” Ledrick says. Several years ago, the Mercy St. Vincent ED was struggling with patient throughput and satisfaction. Surging volumes led to more complaints. “Hospital administration kept turning to us to ‘fix the problem with the department,’” Ledrick recalls.

The ED leadership looked more closely at the issue by keeping statistics on nearly every aspect of a patient’s stay. Soon, they discovered ED processes were not the problem. The real issue was the inability to move admitted patients upstairs.

“Given the number of boarders in the department, we were effectively running an ED out of an inpatient unit. In other words, the department couldn’t be separated from the hospital,” Ledrick reports.

The ED changed its processes to reduce the number of patients who left without being seen. “As simple as it sounds, the solution was getting the patient in front of the doctor as soon as possible,” says Gregory P. Hymel, MD, FACEP, the study’s lead author and assistant medical director of the ED at Mercy St. Vincent.

When the ED fixed this issue, door-to-doctor times and door-to-disposition times shortened significantly. Leave without being seen rates also declined sharply. “When the length of stay began to increase, we went back and evaluated the process again,” Hymel says.

This re-examination revealed there was a specific reason for the longer length of stay: the time from the order to admit to the patient actually leaving the department. Armed with these data, leaders demonstrated the interconnectedness of the department and the hospital. “We were able to come up with some workable solutions,” Ledrick says.

For the past several years, the ED has worked with hospital administrators to significantly reduce delays. Prior to the process change, the door-to-doctor time was 13 minutes.

“We were able to decrease this time to six minutes,” Ledrick reports. Currently, there is a weekly, hospitalwide meeting to identify changes that can lower boarding rates in the ED. It helps that the ED had addressed this issue already from the perspective of a department within a hospital. “We took this on as an issue of a department within a department,” Ledrick explains. “Not surprisingly, we found a similar dynamic.”


  1. Hymel G, Leskovan JJ, Thomas Z, et al. Emergency department boarding of non-trauma patients adversely affects trauma patient length of stay. Cureus 2020;12:e10354.