Hospitals struggle with ED boarding

In the ED, many patients have to wait several hours for an inpatient bed. According to national data from Sg2, patients waited an average of 12.8 hours in the ED for an inpatient bed in 2023. ED boarding can strain limited hospital capacity, contribute to burnout among nurses and physicians, and worsen patients' care experiences and outcomes.

"Boarding is one of the top problems facing the entire emergency care system in the U.S.," said Benjamin Abella, chair of emergency medicine at Mount Sinai Health System in New York City. "It affects everything we do, certainly our ability to appropriately take care of our patients."

"Patients get frustrated as they are sitting on a gurney in a noisy emergency department potentially for days," Abella said. "As much as we try our best, care is not delivered in the same way because we are not inpatient care teams."

"Families might not be ready to send them home, patients may be homeless or they may not have transportation," Shah said. "There are whole other issues with the uninsured and undocumented."

Other factors contributing to longer discharge processes include increased staff turnover at post-acute care providers and increased prior authorization requirements from insurers. Patient discharges also typically take longer on the weekends, when there are fewer hospital or skilled nursing facility staff, as well as during busy flu seasons.

"Health systems have to understand this is not an emergency department flow problem, it takes the entire system to change design, process and structure," said Jason Wilson, founding chair of the emergency medicine department at USF Health Morsani College of Medicine.

How hospitals are addressing ED boarding issues

To address their ED boarding issues, hospitals are turning to several different strategies.

For example, Kent Hospital has created makeshift pods in its ED to function as inpatient units. The hospital has also converted its CPR rooms, placed beds in the hallways, and provided recliner chairs for admitted patients as they wait for an inpatient bed to become available.

"We changed the emergency department layout from how it was initially conceived so we are using every open space," said Daren Girard, chief of emergency medicine at Kent Hospital. "This is the new normal."

To improve its discharge processes, Mount Sinai Hospital has partnered with community organizations to help patients find housing. The hospital also sends social workers throughout the facility to coordinate follow-up calls and visits with patients after they are discharged. 

According to Darcy Jaffe, SVP for clinical excellence at the Washington State Hospital Association, the center has helped improve communication across hospitals, reduce transfer times, and limit ED boarding times.

"It's the glue that holds a very fragile system together across our state because there is no extra capacity," Jaffe said.

Similarly, MyMichigan Health is currently piloting a transfer request program. Through the program, a hospitalist works with clinicians at MyMichigan facilities to prioritize and streamline the process of hospital-to-hospital transfers.

The health system has also appointed a throughput coordinator who flags certain barriers to patients' transfers to skilled nursing facilities, including the use of certain medications or need for specialist consultations. According to Rachel Aultman, MyMichigan's VP of post-acute care, the coordinator has helped reduce excess days by half a day per patient discharge since January 2023.

Some health systems, including Mount Sinai Health System and Providence, have also began offering more virtual care and telehealth services to help reduce their ED and inpatient capacity restraints.

According to Darryl Elmouchi, COO for Providence, increasing telehealth services has been helpful for rural hospitals, but the overall progress has been incremental. "It's like we are running up a hill that keeps getting steeper," he said.

3 strategies to reduce ED boarding and improve patient care

By Jennifer Puzziferro, Senior Director, Optum Advisory and Anne Schmidt, Director, Optum Advisory

This article highlights how ED boarding places immense pressure on healthcare systems, worsening clinician burnout and creating frustrating patient experiences. Burnout among healthcare workers can reduce efficiency, increase the likelihood of medical errors, and diminish capacity to provide empathetic, high-quality care, ultimately impacting patient outcomes. Moreover, burnout contributes to staff turnover, creating shortages that exacerbate the strain on already limited hospital resources.

What the article doesn’t say

ED challenges are compounded by an aging population with increased frailty and complex health conditions, heightening the urgency for realistic solutions. Prolonged ED stays can lead to significant delays in accessing appropriate inpatient care, increased risks of deconditioning, and inefficiencies in healthcare delivery. These extended lengths of stay further stress the workforce, discourage new talent from entering the field, and increase recruitment challenges, perpetuating the cycle of workforce instability.

The implications of burnout and resource shortages underscore the critical need for systemic reforms to address ED boarding and its downstream impact on patient care and clinician well-being. To address these challenges, we propose range of practical and patient-focused solutions, each aimed at improving care delivery while reducing systemic pressures.

Operational best practices

Within the hospital, several targeted interventions can optimize patient flow and help to alleviate capacity constraints. 

• Discharge preparation should begin immediately upon admission, with care teams setting an estimated discharge date to guide treatment plans and identify potential barriers early.
• Interprofessional rounds involving physicians, nurses, social workers, and care coordinators help create proactive treatment and discharge plans, and can identify needs for the actual discharge date, such as arranging transportation, prescriptions, and follow-up appointments.
• Diagnostic tests and imaging should be carefully scheduled, prioritizing those essential to the patient’s care plan while deferring non-urgent procedures to outpatient settings to reduce over-testing and avoid bottlenecks.
• Hospitals can implement real-time bed management systems to monitor availability across units and expedite patient transfers from the ED to inpatient beds. Expanding observation units are often used as a dedicated space for patients needing short-term monitoring without requiring full inpatient admission.
• Deploying Patient Flow Specialists to focus on streamlining complex discharges and coordinating resources can address logistical challenges, such as mobility aids or post-discharge care. 

By refining these internal processes, hospitals can reduce delays and create an environment that supports both efficient operations and positive patient outcomes.

Beyond the hospital

Outside of the hospital environment, there are several opportunities for healthcare organizations to develop relationships and improve patient throughput across the care continuum.   

• Home-first initiatives: These initiatives enable patients to recover safely in familiar environment. Programs like PACE (Program of All-Inclusive Care for the Elderly) can provide comprehensive medical, social, and support services to prevent unnecessary hospitalizations and prioritize home-based care. Collaborations with local foundations help to further enhance geriatric care by supporting caregiver training, mobility aids, and home modifications. These partnerships create robust support systems that promote faster discharges and reduce hospital readmissions.
• Hospital-at-home programs: These innovative solutions to provide acute-level care within the comfort of a patient's home, reducing the need for prolonged hospital stays and helping to keep people in familiar environments. These initiatives can alleviate pressure on EDs and inpatient units while improving patient satisfaction and minimizing exposure to hospital-acquired infections. However, success of hospital-at-home programs hinges on a robust infrastructure, such as reliable remote monitoring tools and home-based medical equipment. Upfront costs for implementing these programs, including workforce training and technology deployment, and equitable access particularly in rural or underserved areas must be considered. Despite these challenges, hospital-at-home models align closely with the "home-first" philosophy, offering a promising pathway to integrate advanced care coordination.
• Paramedic programs: Using these programs for wellness checks can be valuable additions to community health strategies, using paramedics' expertise to conduct proactive home visits and address high-risk patients' needs before they escalate. Their success relies on having sufficient EMS workforce capacity, and local authorities should carefully evaluate recruitment levels, retention efforts, and resource availability to avoid overburdening paramedics, which could compromise emergency responsiveness or lead to scalability issues.

Other tools and considerations

It is critical to ensure patients are well-informed about their care trajectories. By engaging patients and families in shared decision-making, care teams can align treatment plans with patient preferences and set clear expectations for recovery or ongoing management. This transparency reduces anxiety, builds trust, and empowers patients to make educated choices about their care.

Clinically integrating hospitals with primary care providers, specialists, and post-acute facilities further strengthens the care continuum. Ambulatory care management and earlier identification of high- and rising-risk patients also play a critical role. Proactive engagement with care coordinators and frequent check-ins can address potential health risk patients issues early, preventing hospital visits.

Palliative and hospice care are essential elements of a comprehensive care strategy, particularly for patients with advanced illnesses. Offering these services ensures that patients receive appropriate, compassionate care focused on comfort and quality of life rather than prolonging unnecessary hospital stays.

Community health teams (CHTs) can play a pivotal role by deploying social workers, care coordinators, and healthcare navigators to address social determinants of health, such as transportation, housing, and nutrition. CHTs help facilitate smoother discharges, strengthen post-acute care, and limit hospital readmissions. Their work is incredibly impactful in creating tailored care plans for high utilizers and reducing repetitive ED visits.

Advancement in technology can enhance operational efficiency and patient care. Telehealth platforms and virtual urgent care visits divert non-critical cases from the ED.  AI-powered triage systems prioritize patients based on urgency, ensuring optimal care delivery. Wearable technology, remote patient monitoring, and smart ambulances facilitate earlier interventions and personalized care external to the hospital environment. Additionally, predictive analytics tools can improve capacity planning and early identification of patient needs, while mobile health apps empower patients with real-time information and scheduling options.

By integrating these proposed strategies, healthcare systems can take steps toward addressing persistent and multifaceted challenges of ED boarding. While these strategies offer potential improvements, challenges remain significant and may vary based on geographic location and patient population. Systemic reforms are necessary and require sustained effort and investment to create a healthcare model that better supports clinicians, minimizes inefficiencies, and delivers high-quality, safe patient care.