Emergency department boarding — when stabilized patients wait hours or days for transfers to other departments — is a growing crisis.
Ryan Oglesby, Ph.D., M.H.A., RN, CEN, CFRN, NEA-BC
President, Emergency Nurses Association
An elderly woman arrives in the emergency department with a fractured hip. Nurses and doctors assess and stabilize her, and the decision is made to admit her for additional treatment.
The patient waits.
An adolescent experiencing a mental health crisis arrives, is assessed and stabilized, but needs to be transferred to a psychiatric hospital for further care.
The patient waits.
Every day, patients in similar situations wait in emergency departments not equipped for extended inpatient-level care until they can be moved to a bed elsewhere in the hospital or to another facility.
The Emergency Department Benchmark Alliance reports the median waiting time, called ED boarding, is approximately three hours. However, many patients wait much longer, sometimes days or even weeks, and the effects are far-reaching. It has a profound impact on emergency department resources and emergency nurses’ ability to provide safe, quality patient care.
Negatives for patients and providers
When admitted patients remain in the emergency department (ED), nurses juggle inpatient-level care with acute emergencies, leading to heavier and more intense workloads. Although ED nurses are highly adaptable, adjustments to their care approach create further disruptions in what most nurses would already describe as the controlled chaos of the emergency department, where no patient can be turned away.
Research has shown that admitted patients who board in the emergency department have longer overall length of stays and less-than-optimal outcomes compared to those who are not boarded.
Boarding can also exacerbate patient frustration and family concerns about wait times, emotions that often escalate into physical violence against healthcare workers.
Over time, all of these factors increasingly lead emergency nurses to burn out, while the entire emergency care team’s efficiency and morale erode.
Many departments adjust processes, staff roles, and use of space to better tend to their boarded patients, but these are not long-term solutions. Boarding is a whole-hospital challenge, not simply one for the emergency department to figure out.
Recommendations for change
In 2024, Emergency Nurses Association (ENA) representatives were among the contributors to the Agency for Healthcare Research and Quality summit. The event’s findings point to a need for a collaboration between hospital and health system CEOs and providers, as well as regulation and research to establish standards and best practices.
ENA also supports passage of the federal Addressing Boarding and Crowding in the Emergency Department Act (H.R. 2936/S. 1974). The ABC-ED Act would provide opportunities for improving patient flow and hospital capacity by modernizing hospital bed tracking systems, implementing Medicare pilot programs to improve care transitions for those with acute psychiatric needs and the elderly, and evaluating best practices to more rapidly implement successful strategies that minimize boarding.
Boarding is a problem affecting emergency departments, large and small, around the world, but the solutions need to involve decision-makers at the top of the hospital and healthcare systems, as well as front-line healthcare workers who see this crisis firsthand.
Most importantly, those solutions must focus on doing everything to ensure each patient receives the absolute best care possible in ways that also protect the precious health and well-being of emergency nurses and all staff.
