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Unprecedented Strain on EDs Predates COVID-19 Pandemic

By Dorothy Brooks

The authors of two new studies strongly suggest significant change is needed to bolster the U.S. emergency care system after years of mounting strain.

Examining electronic medical record data from 1,769 hospitals across the country over a five-year period, researchers focused on two key metrics of ED strain: the leave without being seen (LWBS) rate and ED boarding.1 “These are the closest metrics that reflect the ‘bottleneck’ in the system,” observes Alexander Janke, MD, MHS, lead author, and a national clinician scholar at the VA Ann Arbor (MI) Healthcare System (VAAHS) and the University of Michigan Institute for Healthcare Policy and Innovation. “If patients board in the ED while awaiting an inpatient bed, that’s a care access barrier. If patients leave without being seen, that’s also a care access barrier.”

The findings on each metric reveal a worsening problem that predates the COVID-19 pandemic. For example, while studying the LWBS rate, Janke and colleagues found this metric doubled from 2017 to the end of 2021, growing from slightly more than 1% to just over 2%. Further, researchers found that by the end of the study, 5% of participant hospitals reported more than 10% of patients left before receiving a medical exam, which also was more than double the LWBS rate from these same hospitals in 2017.

In the second study, Janke and the same colleagues measured the number of hours admitted patients had to board in the ED before receiving a hospital bed. They compared this information to the occupancy level of each hospital when boarding occurred.2 When hospitals reported more than 85% of their staffed inpatient beds were full, admitted patients in the ED had to board for more than four hours before receiving an inpatient bed nearly 90% of the time. On average, these patients waited more than 6.5 hours for an inpatient bed. This compares with a boarding time of just 2.4 hours when hospitals were less full.

While The Joint Commission recommends keeping boarding times shorter than four hours to prevent care delays and other safety issues,3 researchers reported that by the end of the study period, the median boarding time neared that level (3.4 hours). However, at the 5% of hospitals with the highest occupancy rates, median boarding times topped nine hours. Also, researchers noted while hospital bed occupancy levels did not change much from 2020 to 2021, the number of visits to the ED grew along with boarding times.

With pandemic-related surges easing, some hospital leaders and policymakers may be expecting the pressure on EDs to ease, but Janke stresses that is not what the evidence suggests. “We’re two years in and that thinking doesn’t seem to have served us well so far,” says Janke, an emergency physician at the VAAHS and Hurley Hospital in Flint, MI. “Given the ongoing RSV/influenza wave that’s wrecking pediatric hospitals, I think it’s clear this is not just [a COVID-centric problem].”

Janke stresses redirecting patients elsewhere cannot relieve this strain. “Patients boarding [and] waiting in the ED for long periods of time for an inpatient bed are not the sort that can be redirected to lower-acuity settings,” he says. “We have 30 years of academic and operational work around redirecting patients to lower-acuity settings [and] focusing on ‘unnecessary’ ED visits.”

Instead, Janke says the problem is connected to ED staffing, the availability of hospital beds, skilled nursing facility space, and capacity in broader community settings. Unfortunately, this message has not yet sufficiently reached policymakers or the public. “Part of my work is centered on bringing up-to-date data to the forefront,” Janke says. “We need to do a better job telling the story of the harm this causes. We want to communicate that system strain means that when your kid gets sick or when you get in a car accident, the system may not be ready for that.”

In November, the American College of Emergency Physicians (ACEP) and other groups sent a letter to the White House in which they declared the boarding problem a “public health emergency.” The groups asked the Biden administration “to convene a summit of stakeholders from across the healthcare system to identify immediate and long-term solutions to this urgent problem.”4

Along with that letter, the groups included a special report created by ACEP that features anecdotes from frontline providers about how boarding has affected their facilities, along with results of a qualitative analysis.5

Arjun Venkatesh, MD, MBA, MHS, who worked with Janke on the LWBS and boarding studies, notes crowding in most EDs is not the result of short staffing or limited space; physicians and nurses are spending so much time caring for patients who are boarding in the ED while waiting for an inpatient bed.

“Often, those inpatient services are also trying to improve efficiency in any way possible, but they are facing their own capacity challenges as nursing homes lack the staff to accept patients ready for discharge,” says Venkatesh, an associate professor and chief of the section on administration in the department of emergency medicine at Yale. “Also, hospitals are increasingly taxed with performing care that can’t be provided in the outpatient setting, as COVID resulted in [more] retirements and closures of primary care doctors [offices], urgent care centers, and other access points. This extra care further overburdens the system, alongside limited staffing in the hospital.”

Far from addressing the root causes of this strain, some policy decisions have gone in the opposite direction, Venkatesh argues. For instance, he cites the decision by CMS to retire the hospital boarding measure as one move that has been counterproductive.6 “We are hoping that ED boarding, and really hospital capacity, can be put back on the policymaker agenda by reinvigorating measurement and value-based purchasing programs that favor reducing ED strain by regulatory relief so that hospitals and EDs can flexibly care for patients across settings,” says Venkatesh, a scientist at the Yale Center for Outcomes Research and Evaluation.

Other moves Venkatesh would like to see include payment changes to favor telemedicine or moving more care from inpatient to outpatient settings. He also would like to see an expansion of automation to reduce paperwork so clinicians can be at the bedside instead of at their computers.

Venkatesh is hopeful that as the pandemic eases, attention to the capacity issues highlighted in his studies will receive new focus.

“I hope attention is not lost and that the pandemic merely creates awareness of a problem that existed even before the pandemic,” he says. “Patients and providers can continue to keep attention on this issue by sharing stories, focusing efforts directed at policymakers to address this issue, and by showing emergency clinicians a little empathy to understand the unforeseen and unsustainable work conditions they find themselves in.”


1. Janke AT, Melnick ER, Venkatesh AK. Monthly rates of patients who left before accessing care in US emergency departments, 2017-2021. JAMA Netw Open 2022;5:e2233708.

2. Janke AT, Melnick ER, Venkatesh AK. Hospital occupancy and emergency department boarding during the COVID-19 pandemic. JAMA Netw Open 2022;5:e223364.

3. The Joint Commission. Patient flow through the emergency department. R3 Report. Dec. 19, 2012.

4. American College of Emergency Physicians. Letter to the White House. Nov. 7, 2022.

5. American College of Emergency Physicians. A Nation in Crisis: Real Stories from the Front Lines.

6. Centers for Medicare & Medicaid Services. Admit decision time to ED departure time for admitted patients. Federal Register. Aug. 13, 2021.