Title: The Boarding Dilemma in Emergency Departments: A Reflection of a Strained System
Emergency departments (EDs) throughout the United States are grappling with a growing crisis—boarding. This term describes the practice of keeping admitted patients in the ED due to insufficient inpatient beds. What was once a rare inconvenience has morphed into a persistent challenge affecting patient outcomes, staff exhaustion, and the overall standard of care.
On a recent evening in a 31-bed ED, nearly every room was occupied. More than 20 patients were either in the waiting area or seated in makeshift “rooms” behind the triage desk. Ten of the patients within the department were boarding—awaiting inpatient beds, psychiatric placements, or transfers to specialized care facilities. In this environment, one physician and a nurse practitioner were tasked with a demanding patient load, including a critical case needing ventilation, blood transfusion, vasopressors, and intensive sedation. The volume of EKGs increased, but the staff struggled to keep up.
This scenario, though alarming, is not an isolated incident.
Grasping the Boarding Crisis
Boarding is not simply a nuisance—it represents a bottleneck in healthcare with perilous repercussions. Research repeatedly indicates that extended stays in emergency departments for admitted patients are linked to heightened mortality rates, particularly among the elderly. Furthermore, boarding correlates with increased occurrences of hospital-acquired infections, medical errors, patient agitation, and poor outcomes for psychiatric individuals.
So, what are the underlying causes of boarding?
1. Shortage of Inpatient Beds
Hospitals contend with ongoing bed shortages, primarily due to an absence of available nursing staff—a national issue worsened by post-pandemic departures and employee burnout. A reduced number of nurses translates to fewer available inpatient beds, rather than fewer hospital rooms. This backlog hampers the ED’s capacity to transfer admitted patients to appropriate hospital units.
2. Delays in Long-Term Care Placements
Patients who are medically cleared for discharge frequently remain in hospitals due to delays in securing placements in nursing homes, rehabilitation centers, or assisted living facilities. As long-term care options become strained and admissions are complicated by factors like funding and regulation, these patients can stay in hospital beds for days or even weeks, contributing to flow issues and gridlock.
3. Crises in Mental Health and Addiction
Mental health crises and substance abuse complications further exacerbate the boarding issue. Individuals facing acute psychiatric crises may remain in the ED for hours or days while awaiting placement in state or private psychiatric facilities. Delays in placement often stem from limited capacity, strict admission criteria, and difficulties in managing concurrent physical health issues.
4. Increased Transfers and Defensive Medical Practices
Hospitals, especially smaller facilities with limited specialty services or ICU capabilities, often transfer patients to specialized centers. Legal concerns and administrative challenges foster an environment where even borderline cases are shifted rather than accepted locally. Such transfers can consume hours or longer as specialty beds in referral hospitals become few and transport logistics become strained by limited ambulances and air medical units.
5. Systemic Policy and Prioritization Issues
Hospitals frequently prioritize elective surgeries because of their higher reimbursement rates, maintaining inpatient beds for anticipated admissions post-procedure. While this strategy is financially viable, it inadvertently supports ED congestion. Decisions made with the hospital’s financial health in view often overlook the immediate crises unfolding in the ED.
The Human Cost
ED personnel are trained for rapid, high-pressure, life-and-death decision-making, not for dealing with hospital overflow continuously. The emotional and cognitive toll on healthcare workers in an overcrowded ED is profound. Burnout is widespread, intensified by moral injury— the psychological damage resulting from being unable to provide expected levels of care due to systemic failures.
Additionally, this affects patients yet to be seen. The prevailing misconception that individuals who leave before evaluation aren’t seriously ill is incorrect. Many patients depart out of discomfort, anxiety, and exhaustion after spending hours in crowded spaces void of privacy and necessary resources. Some of these individuals may deteriorate or even succumb outside the hospital after unsuccessful encounters.
Infectious disease concerns also emerge in these crowded conditions. During flu seasons—or surges of COVID-19—placing patients in close proximity for hours or days enhances the risk of cross-infection, potentially transforming EDs into sources of community outbreaks.
A Call for Reform
Emergency healthcare practitioners do not shy away from hard work. They accept stress and intensity as part of their roles. However, the ongoing lack of support, clarity, and effective solutions from hospital administrations and health policy leaders has left many feeling discarded. While healthcare systems concentrate on patient satisfaction and outcomes, they frequently neglect the pressing need to enhance operational infrastructure within the ED—where patients first enter the hospital system.
Solutions may be elusive, but several potential avenues include:
– Providing incentives for inpatient units to accept ED admissions more swiftly, even if it means temporarily boarding patients in inpatient hallways—a practice that is suggested but seldom enacted.
– Investing in community-based care, rehabilitation, and mental health resources to alleviate the strain on hospitals.