Study: Hospitals struggle to eliminate ED boarding

Leadership needed to beat back resistance

Emergency department administrators are well aware that crowding in the ED is associated with poorer patient outcomes, longer hospital stays, and decreased patient satisfaction. Yet a new study, published in Health Affairs, makes the case that even in the face of steadily increasing demand for emergency care, EDs are failing to take advantage of proven strategies to ease crowding.1

Every ED has its own unique challenges, but Elaine Rabin, MD, the lead author of the study and an assistant professor in the Department of Emergency Medicine at Mount Sinai Hospital in New York, suggests that one of the primary reasons for this failure is that patient boarding in the ED, one of the main drivers of crowding, is actually a hospital-level problem.

Patient boarding is the practice of holding admitted patients in the ED for long stretches of time, purportedly because inpatient beds are not yet available. Virtually no one approves of the practice, but boarding is nonetheless widespread, even though it adversely impacts an ED's capacity to care for new patients.

"The only way for boarding to be eliminated is for inpatient beds to open up more quickly for ED patients," explains Rabin. But actually getting the staff on inpatient floors to turn over the beds more quickly requires interdepartmental coordination, she adds. "It has been pretty clear from the people who have actually solved this problem that unless the leadership of the hospital is behind this, it doesn't happen."

Further, some hospital administrators appear to be more incentivized to address ED boarding than others, depending on the payer mix a hospital is accustomed to dealing with. "There are some hospitals where the majority of reimbursement comes from admissions through the ED, and there are hospitals where that is not true, so this will vary ... but there is a good amount of anecdotal evidence that hospital leadership is, in some cases, actively saving beds for better reimbursed patients."

Smooth schedule for elective procedures

What can hospitals do to reduce crowding? The Health Affairs study highlights several strategies that the authors suggest can remove admitted patients from ED hallways and facilitate throughput. For example, at many hospitals, scheduled catheterizations and elective surgeries are heavily booked in the early part of the week. The authors note that taking steps to smooth out this schedule so that procedures are evenly booked throughout the week can go a long way toward eliminating patient surges and the accompanying bottlenecks that can lead to boarding.

The strategy sounds like an easy fix, but Rabin suggests that hospital administrators often run into obstacles when trying to even out the schedule in this way. "There tends to be a lot of resistance up front, and certainly hospital administrators don't want to alienate surgeons who bring in a lot of money by trying to force them to operate on days when they don't want to operate," she says.

However, Rabin suggests that hospital leaders at Boston City Hospital, for example, have had success working closely with their surgeons to gradually smooth out the schedule so that elective procedures are not so front-loaded in the early days of the week. "It took a lot of gentle massaging of politics, but once it happened, the surgeons actually liked it better because without over-booking, the operating rooms actually ran on time and their schedules were more predictable," she says.

Move boarded patients to inpatient halls

Another strategy highlighted in the study involves moving patients boarded in the ED up to inpatient floor hallways where they can wait for a bed to be opened. "Peter Viccellio, MD, [clinical director of the Department of Emergency Medicine at Stony Brook University Hospital in Stony Brook, NY] is a big advocate of this, and he has demonstrated that it is safe," observes Rabin.2 "It would be hard to argue that being on a quiet hallway on an inpatient floor is going to be worse for patients than being in a loud environment in the ED where the nurses might have 10 other patients and the doctors have their attention spread thin as well."

Advocates of this approach, such as Stephen Pitts, MD, MPH, an associate professor in the Department of Emergency Medicine at Emory University in Atlanta, say the approach should be a slam dunk. "The ED is the worst place [for these patients] because that is where you need the new beds to turn around, and yet that is where patients end up because that is the tradition. This is an underused strategy," says Pitts. "The concept of taking patients who are in [the ED] hallways and putting them in the hallways in front of a bed they are about to occupy, makes perfect sense from the standpoint of safety and quality and, in fact, when a patient does get up onto an inpatient floor, their bed is often cleaned and ready to go more quickly."

However, Pitts points out that the strategy often becomes difficult to implement because of resistance from inpatient staff. "This is an added burden for them with no benefit," he says. "It would be much easier for them if the patient stayed in the ED until the inpatient bed was ready." In light of this resistance, Rabin suggests this is another clear instance in which hospital-level leadership is required for successful implementation.

Put a bed czar in charge of patient flow

A third anti-crowding strategy that an increasing number of hospitals are gravitating toward is the creation of a new position, often referred to as a bed czar, to oversee bed utilization and take charge when bottlenecks occur. "Everyone who works in the ED knows that when there isn't someone looking at the big picture, things get lost," says Rabin, noting that you can have one patient waiting for a bed on an orthopedic service for a day and a half while there are 10 beds available on the renal service. "Having someone oversee all of that makes a big difference."

Pitts agrees, explaining that it is a full-time job to make sure patients are moving through the system efficiently. "It used to be common for us to have horrible congestion in the ED with no space to see new patients, and I would go upstairs to see all of these supposedly uncleaned beds ... and I would see one bed after another open for business, so there was this huge disconnect over what was being told and what was actually happening up there," he says. "These bed czars are the people who can actually match supply and demand and ease some of the congestion in the ED."

The most effective bed czars tend to be people with clinical as well as administrative skills, says Rabin, because it is important to have an understanding of which patients can safely go to what services. "Their territory is the whole hospital," she says.

"The underlying concept behind the bed czar, and really all of these solutions, is that the ED operates 24/7, but the rest of the hospital traditionally has not, so that can cause a lot of inefficiencies where patients might stay half a day longer than they need to just because they are waiting for a certain specialist who doesn't come in until 3 o'clock in the afternoon," explains Rabin. "Having a bed czar and having services available more hours in the day can make throughput more efficient."

Consider impact of practice intensity

While the link between boarding and crowding in the ED is crystal clear, less well-understood is the impact that practice intensity has had on ED crowding in recent years. To look at this issue, Pitts and colleagues analyzed patient data for ED visits between 2001 and 2008. They found that visits to the ED increased 60% faster than population growth during this period, and that crowding grew even more rapidly, mostly because of diagnostic tests and treatment intensity.3

In fact, Pitts suggests that the front loading of blood work, X-rays, and other tests ordered during triage may well be bogging down patient flow rather than speeding things along, as the practice was intended to do. However, he adds that some of this intensity has been driven by research findings and technological innovations.

"If you were to come in with chest pain in 2000, the chances of having a CT scan of the chest were much lower then they are now just because CT scan of the chest is now viewed as a good test for pulmonary embolism, but it wasn't back in 2000," explains Pitts. Similarly, ultrasound, which used to be rarely used in the ED, is now used routinely in some cases, he says. "People get more stuff done to them these days, but they are also discharged from the ED much more frequently than they used to be, so it saves inpatient resources in a sense. However, this front loads the ED with all the work that used to be done in the hospital."

While changes in the practice of medicine have driven much of this intensity, Pitts observes that it is also important to consider that the population of ED patients has also rapidly become older and sicker. During the study period, researchers found that Medicare patients aged 45 to 64 grew faster than all other age groups, and this group includes patients who tend to be poor, disabled, and cognitively challenged, says Pitts.

"In 2009, 38% of the Medicare patients under the age of 65 were also Medicaid recipients, but even patients who are not dual-eligible are sicker in general, and they are less able to manage their affairs," explains Pitts. "The character of patients [who come to the ED] has changed, so the input part of the equation has changed. The output — the ability to admit patients upstairs — has changed, but the throughput has also changed because we are doing more stuff to the same people who have arrived."

Pitts acknowledges that at least some of this increased practice intensity has improved care, but there have also clearly been consequences on patient flow. "I started practicing in 1980, and I used to see 30 patients in a shift not uncommonly because we discharged people without further ado," he says. "I am lucky to see 15 patients in a shift now because of the complexity of the workup."

Satisfaction surveys push intensity of care

Pitts observes that there are two other "forces" that have driven up practice intensity and adversely impacted patient throughput. First, he points to Medicare's adoption of Evaluation and Management Coding (E/M) — the method of billing for services that was adopted in the late 1990s. "This really put a massive break on turnaround times and the ability to see a lot of patients, because in order to collect money, you had to do lots of stuff," explains Pitts.

The approach, which has become common practice among all payers, has led to over-documentation for relatively minor complaints, says Pitts, but he also stresses that E/M coding enables clinicians to collect more money from the same patients because more services are documented.

Also, while perception of legal risk is undoubtedly responsible for some overtreatment, Pitts suggests that a more important driver of utilization is the increasing practice of grading ED physicians on patient satisfaction surveys. "Patients are far more satisfied if you do a lot of stuff than if you don't; there is no doubt whatsoever about that," says Pitts. "It is clear that people think they get better care when they get more care."

While a massive expansion of primary care access could take some of the pressure off of EDs, Pitts suggests it is unlikely that the trend toward providing more care in the ED is going to reverse any time soon. "Skimping on care is nobody's favorite strategy; it is going to be very hard to do that."


  1. Rabin E, Kocher K, McClelland M, et al. Solutions to emergency department "boarding" and crowding are underused and may need to be legislated. Health Affairs 2012;31:1757-1766.
  2. Viccellio A, Santora C, Singer AJ, et al. The association between transfer of emergency department boarders to inpatient hallways and mortality: A 4-year experience. Ann Emerg Med 2009;54:487-491.
  3. Pitts S, Pines J, Handrigan M, et al. National trends in emergency department occupancy 2001 to 2008: Effect of inpatient admissions versus emergency department practice intensity. Ann Emerg Med 2012 June 20. [Epub ahead of print].


  • Stephen Pitts, MD, MPH, Associate Professor, Department of Emergency Medicine, Emory University, Atlanta, GA. E-mail:
  • Elaine Rabin, MD, Assistant Professor, Department of Emergency Medicine, Mount Sinai Hospital, New York, NY. E-mail: