According to previous research, boarding inpatients in EDs is one of the main drivers for crowding. In the August 2012 issue of Health Affairs, my colleagues and I explained what is known about the causes and dangerous effects of boarding, strategies that have been demonstrated to alleviate boarding but are underused, and possible regulatory steps that will be needed for hospital leaders to increase efforts to address boarding.

Crowding & Boarding: A Costly Problem

Inpatients who are boarded in EDs burden already busy ED staff and are kept in brightly lit, loud environments for many hours or even days. Not surprisingly, studies have shown that boarding increases morbidity and mortality, lengthens hospital stays and durations of intubation, worsens pain control, and compromises care. Patients may also have greater exposure to hospital-acquired infections. Boarding also affects measures to which hospitals are held accountable, including time to receipt of antibiotics for patients with pneumonia and the development of bedsores. Furthermore, long waits due to crowding cause some patients to leave EDs before being seen by physicians, robbing them of care and decreasing hospital revenue from their visit.

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Boarding occurs when inpatient beds are not available to patients admitted through the ED. This sometimes is the result of hospitals being at full capacity, but inefficient operations may also be partly to blame. Even when hospitals are not at full capacity, hospital leaders who don’t fully understand the costs of boarding may preferentially reserve beds for patients whom they consider more profitable than ED patients (eg, elective surgery patients for whose care is assured reimbursement). Evidence is mixed on whether this is actually a profitable strategy.

Are Strategies Effective in Reducing Boarding?

Several strategies have been shown to reduce boarding, often without eliminating elective surgeries or other well-reimbursed activities. These include better management of bed assignments and other inpatient services and moving patients to hallways on inpatient units. Smoothing surgical schedules can also eliminate peaks in bed demand that occur from many surgeons’ preferences to schedule surgeries early in the week.

However, true change can only occur when hospital leadership is committed to eliminating boarding. That said, additional government regulations may be required. A first step will be taken in 2014, when CMS will institute a pay-for-reporting program that will offer financial incentives for reporting ED length of stay for admitted and discharged patients and boarding times. Converting the pay-for-reporting into a pay-for-performance program could incentivize hospitals to address boarding.

Next Steps to Solve ED Boarding

Large, multi-center studies are needed to help provide concrete evidence of the most effective and feasible solutions to ED boarding. Until then, emergency physicians and staff should make efforts to ensure that hospital leadership understands how ED boarding compromises patient care and satisfaction, staff well-being, and hospitals’ ability to meet core measures. With buy-in from hospital leadership, viable solutions can be implemented to help solve the problem of ED boarding.


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. Available at

Lucas R, Farley H, Twanmoh J, et al. Measuring the opportunity loss of time spent boarding admitted patients in the emergency department: a multihospital analysis. J Healthc Manag. 2009;54:117-124.

Singer A, Thode H, Vicellio P, Pines J. The association between length of emergency department boarding and mortality. Acad Emerg Med. 2011;18:1324-1329.

Howell E, Bessman E, Kravet S, et al. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149:804-811.

Powell E, Khare R, Venkatesh A, et al. The relationship between inpatient discharge timing and emergency department boarding. J Emerg Med. 2012;42:186-196.

Khare R, Powell E, Reinhardt G, Lucenti M. Adding more beds to the emergency department or reducing admitted patient boarding times: which has a more significant influence on emergency department congestion? Ann Emerg Med. 2009;53:575-585.