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ED Boarding

We have been discussing ED boarding for well over 20 years. There are numerous resources that have suggested methods to combat the problem. What once was a problem easily fixed by moving people out of the ED and parking them on nursing units, has become an increasingly complex beast. If your hospital is struggling, like most, then a review of your assumptions, methods, and measures may yield some insight into the problem. Here is a quick run:

Causes of the problem:

  • Increasing Patient Volume: there are fewer hospitals in existence today than there were 10 years ago, and more people around to visit them. In addition, this past season gave us excessively high volumes from a national flu epidemic. Add to that a turbulent political environment for primary care and diminishing psychiatric services, and we have lots of competition for few resources. 3
  • Lack of bed space: You may still believe that bed space is the issue. However, over the last 2 decades there have been numerous studies and large hospital case reports proving that adding beds does not fix this issue. It may temporarily alleviate the problem, but it will not result in a lasting solution. Drop this from your list.
  • Insufficient staffing: This one is huge. There continues to be a national shortage of nurses. Many large hospital systems are suffering and unable to staff their existing beds. Though an organization may be “licensed” for a certain number of beds, a better question would be how many beds are truly operational 24/7 and how many are only open certain days or hours. This gives you a more realistic view of capacity at your hospital.
  • Poor efficiency: This is generally not a root cause of the problem, but it is certainly a large contributor. Inefficiencies that were tolerable 20 years ago are no longer acceptable. These include: preferential surgical scheduling, service availability during business hours only, weekend discrepancies in rounding, weekend discrepancies in staffing, weekend/holiday discrepancies in discharge to nursing or rehab, etc… In addition, the increase of administrative tasks for clinical staff (documentation requirements, screening questions, regulatory “suggestions”, etc) reduces efficiency and the price is payed by the patient. More on this below…

The process of improvement: 

In the past, solutions to ED boarding have been discussed as though single changes would fix the problem. However, increasing evidence has shown that ED boarding requires 4 :
  • A non-ED focus. ED boarding is a symptom of poor hospital flow and function, not a symptom of poor emergency department function.
  • A critical evaluation of every step in the inpatient process, with specific focus on areas where large gains can be obtained.
  • A group of people with oversight and authority to impact real change in each of their areas within the hospital.
  • Senior administration involvement (not simply support).
  • Simultaneous changes in multiple areas. A single change is insufficient.

Items proven to help:

  • Full capacity protocol: we’ve discussed this before so I will not spend much time reviewing its successes. In short, this protocol places admitted patients in hallways allowing for inpatient nurses to care for them, despite the lack of a room. If your hospital is short nurses (very likely) and you are already at the maximal tolerable patient/nurse ratio due to legal mandates or safety constraints, this solution cannot be implemented.
  • Data: Access to the necessary data is required. However, you need to measure correctly.
    • Recent evidence suggests that mortality within the first 24 hours is unaffected by boarding, but that overall hospital mortality increases. Make sure you are reviewing the dat encompassing the entire hospital stay. 1,6,7
    • In addition, recent studies have suggested that boarding is skewed towards patients admitted to medical services instead of surgical, pediatric, or ICU services. You may benefit from reviewing data by service line to see if this is true for your hospital. Medical services typically carry the brunt of the elderly and higher acuity illnesses with prolonged recovery times. 5
    • Ancillary departments need to be held to performance measures. If no national benchmarks are available (see EDBA, ACEP, etc) then internal goals should be set by a multi-department group. Goals should be realistic, achievable, and accountability needs to be present 24/7.
  • Non-flow related inefficiencies should be discussed and rectified in order to improve staff workflow:
    • Unnecessary tasks should be eliminated. 2
    • Employee workflow needs to be closely examined for waste. If you are unfamiliar with this process, use a consultant to get the ball rolling. 2
    • Barriers to admission must be eliminated (slow call backs, additional testing requests before admission, poor provider staffing, etc.) 2
    • Housekeeping should not be a barrier. Review staffing, turn around time, hours, and processes.
  • Administration support – Hospitals with the best performance have engagement from the chief executives. A passions for the correct work, at the correct time, with the correct behavior is necessary. It is rare to find transformative change that is simply “supported” instead of being led by the c-suite. 8

In summary, if you are still focused on the single bullet solution, you are going to fail. Evaluate ALL the steps in the process, all services, all providers, with a critical eye for efficiency. And keep in mind, maximizing staff efficiency requires change in their workflow as well as accommodation from the patient. More patient movement may be necessary to accommodate the providers, but this is not a bad thing. No mortality risk has ever been linked to increased patient movement.


  1. Coil CJ, Flood JD, Belyeu BM, Young P, Kaji AH, Lewis RJ. The Effect of Emergency Department Boarding on Order Completion. Ann Emerg Med. 2016;67(6):730-736.e2. PubMed
  2. Amarasingham R, Swanson TS, Treichler DB, Amarasingham SN, Reed WG. A rapid admission protocol to reduce emergency department boarding times. Qual Saf Health Care. 2010;19(3):200-4.  PubMed
  3. Pitts SR, Vaughns FL, Gautreau MA, Cogdell MW, Meisel Z. A cross-sectional study of emergency department boarding practices in the United States. Acad Emerg Med. 2014;21(5):497-503. PubMed
  4. Rabin E, Kocher K, Mcclelland M, et al. Solutions to emergency department ‘boarding’ and crowding are underused and may need to be legislated. Health Aff (Millwood). 2012;31(8):1757-66.  PubMedDirect Download
  5. Salehi L, Phalpher P, Valani R, et al. Emergency department boarding: a descriptive analysis and measurement of impact on outcomes. CJEM. 2018;:1-9. PubMed
  6. Lord K, Parwani V, Ulrich A, et al. Emergency department boarding and adverse hospitalization outcomes among patients admitted to a general medical service. Am J Emerg Med. 2018; PubMed
  7. Singer AJ, Thode HC, Viccellio P, Pines JM. The association between length of emergency department boarding and mortality. Acad Emerg Med. 2011;18(12):1324-9. PubMed
  8. Chang AM, Cohen DJ, Lin A, et al. Hospital Strategies for Reducing Emergency Department Crowding: A Mixed-Methods Study. Ann Emerg Med. 2018;71(4):497-505.e4. PubMed

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