Patients who are admitted, but held in the ED waiting for an inpatient bed to become available, are known to be at risk for increased morbidity and mortality.1-4 However, it was unclear how boarding affects admitted patients generally.

“We aimed to understand patient boarding from the experience of ED patients by evaluating the variables known to influence ED throughput each day,” says Leslie A. Laam, PhD, lead business intelligence analyst at Steele Institute for Health Innovation in Danville, PA.

Laam and colleagues analyzed 466,449 encounters in two large EDs that occurred from 2015-2019.5 “Our results confirmed the sense that ED boarding harms all admitted patients, not just boarded ones,” Laam reports.

The median length of stay for all admitted patients increased 12.4 minutes in one ED and 14 minutes in the other ED for every boarded patient. In addition to boarding, Laam and colleagues studied other variables, such as quality improvement efforts and hospital capacity. “ED boarding is the result of larger system factors. The ED is where the problem is felt, but it’s not necessarily where it begins,” Laam observes.

It is not just the ED. Inpatient units, patient placement, and environmental services also are involved. “Teams must understand their role in the larger process,” Laam says. “All should be working toward the same goal, held accountable by leaders throughout the organization.”

David Ledrick, MD, says ED boarding means the system is “broken somewhere.” Possibly, the hospital lacks available beds because of an inability to discharge inpatients. ED boarding also happens if housekeeping is understaffed, making bed turnaround difficult. “Hospitals are built for a set capacity, but not necessarily for surges in volume,” says Ledrick, associate residency director and clinical clerkship director in the department of emergency medicine at Mercy St. Vincent Medical Center in Toledo, OH.

When administrators create a budget for a daily schedule, staffing is based on historical trends. “But in a tight economy, having additional staff around ‘just in case’ is difficult to afford,” Ledrick says.

During the COVID-19 pandemic, as many as 25 patients might be boarded at one time in Mercy St. Vincent Medical Center’s ED. Boarding that many patients “is inefficient, full of communication errors, and has unclear lines of responsibility,” Ledrick says.

ED waiting rooms are full with patients still waiting to be seen. Meanwhile, the boarded admitted patients are cared for by nurses not trained in inpatient care. “All the medical personnel are running from one brushfire to the next, without the resources they need in a healthcare gridlock,” Ledrick notes.

Boarded patients are put at risk if they miss scheduled doses of antibiotics or steroids. Other ED patients are at risk of remaining stuck in a waiting room or left off a necessary monitor. Critical lab results may go unrecognized or unreported. From the EP’s perspective, says Ledrick, two things are most important: maintain clear lines of responsibility and eliminate barriers to communication between EPs and bedside nurses.

On inpatient floors, physicians are not always present. They depend on others at the bedside to carry out treatment protocols and alert them to deviations in care or a deterioration in condition. “These models break down when an inpatient is in the ED,” Ledrick reports.

Often, it is difficult for an inpatient physician to learn information about an admitted patient. ED nurses must prioritize acute, newly arrived, and unstable patients. “It is difficult to use inpatient charting and ordering systems in the acute care setting of the ED,” Ledrick adds.

To help, move the inpatients to a specified area of the ED with personnel who are familiar with inpatient care. Assign an EP to act as a hospitalist for the inpatient services. Staff the ED with additional nurses from the inpatient units. Finally, move boarded ED patients to inpatient floors in hallway beds. “If they are going to be in a hallway bed anyway, they may as well be upstairs,” Ledrick offers.

ED boarding “isn’t as much an ED problem as it is an inpatient problem,” according to Lindsey Woodworth, PhD, an assistant professor of economics at University of South Carolina who studies health economics. Correcting the problem likely will require buy-in from hospital administrators, which is no easy task.

Part of the solution requires beds in inpatient wards to be opened — beds that are occupied by patients receiving lucrative elective procedures. “This potentially affects hospital profitability if inpatient beds are repurposed to accommodate backlog in the ED,” Woodworth says.

But what happens if there is an adverse event in the ED? “A lawsuit could inflict a heavy blow on a hospital, potentially heavier than the blow that would come from pre-emptively allocating more inpatient bed space to non-profitable emergency patients,” Woodworth says.


  1. Sun BC, Hsia RY, Weiss RE, et al. Effect of emergency department crowding on outcomes of admitted patients. Ann Emerg Med 2013;61:605-611.e6.
  2. Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust 2006;184:213-216.
  3. Bernstein SL, Aronsky D, Duseja R, et al. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med 2009;16:1-10.
  4. Singer AJ, Thode HC Jr, Viccellio P, Pines JM. The association between length of emergency department boarding and mortality. Acad Emerg Med 2011;18:1324-1329.
  5. Laam LA, Wary AA, Strony RS, et al. Quantifying the impact of patient boarding on emergency department length of stay: All admitted patients are negatively affected by boarding. J Am Coll Emerg Physicians Open 2021;2:e12401.