The key messages below can support ACEP members in the creation of materials to address boarding in the emergency department. Please feel free to use and customize these points for social media posts, interviews with reporters, speaking engagements, or other thought leadership opportunities.
The most compelling call to action is your personal story. ACEP is gathering member stories for advocacy purposes; to paint a stark picture of a system near collapse, to show that patients are at risk of avoidable harm, and to detail firsthand how emergency care teams are strained to their limits. Strengthen ACEP advocacy by anonymously detailing your experience here. Contact PR@acep.org with any questions about sharing your personal story.
Boarding in the ED Has Become a National Crisis
Challenges that stem from boarding have persisted for decades, but these issues have new urgency today.
- Patient “boarding”—where admitted patients wait for an inpatient bed or appropriate care transfer—which in recent months has brought our nation’s emergency departments to a breaking point.
- Emergency departments across the country are experiencing significant spikes in demand for emergency care and services and facing a "triple threat" of flu, COVID-19, and respiratory illnesses like RSV.
- With nurse and staff shortages spreading, the influx of patients boarding in the emergency department for extended periods of time is adding more stress on the system, exacerbating emergency physician burnout, and compounding care delivery challenges.
Although it certainly has added to strain, COVID-19 didn’t cause the boarding crisis.
- The pandemic only exacerbates the challenges that contribute to boarding and the consequences that emergency physicians and patients face as a result.
- Many nurses and other health care staff burned out and left the profession altogether during COVID-19
- For decades, hospitals and health care systems have prioritized efforts to maintain inpatient capacity with less attention dedicated to staffing and resources. The patient bottleneck that results from this misaligned focus, as well as the current unprecedented staffing shortages, puts a unique strain on emergency departments, which aren't as subject to staffing ratio requirements.
COVID protections on their own won't fix the problem of boarding in the ED.
- COVID safety measures such as encouraging masks are helpful in reducing the spread of the virus and potentially keeping people out of the hospital, but the causes of boarding are systemic and multifactorial.
- COVID, flu, and other respiratory virus patients are often in and out relatively quickly—it is patients waiting hours, days, or even weeks for an inpatient bed or transfer to a nursing or psychiatric facility that cause the bigger logjam.
Challenges for Patients
Boarding harms patients and leads to worse health outcomes.
- There is no question that boarding harms patients.
- More than 70 studies confirm that consequences from boarding can include worse health outcomes, increased medical errors, privacy compromises, and in some cases avoidable deaths.
- Emergency departments across the country are at capacity and overflowing.
- Care teams are sometimes forced to treat patients on stretchers in the middle of the hallway or even in the waiting room until beds become available.
- Long wait times can cause potentially deadly delays.
- The Joint Commission recommends that boarding times stay below four hours to avoid delays in care or safety issues.
- Many emergency physicians routinely experience boarding times much longer than that.
- ACEP collected more than 100 personal stories from emergency physicians across the country and nearly all (97%) cited boarding times of more than 24-hours, one third (33%) have had patients stay more than one week, and 28% over two weeks.
The most vulnerable patients are some of the most at risk, especially those struggling with mental health challenges.
- The emergency department is the most appropriate setting for unscheduled emergency care, but the often disruptive environment is not ideal for long-term treatment of mental and behavioral health needs.
- Patients who experience mental health emergencies wait for care on average three times longer than other patients, according to a 2016 survey of ACEP members.
- Still, far too many Americans have limited options for mental health care outside of the emergency department.
Challenges for Physicians
Boarding is not only detrimental to patient care, it contributes to burnout and adds to staff shortages.
- Emergency care teams are doing all they can to treat every patient. But many emergency physicians feel helpless as they see patients get preventable illnesses or even die, because hospitals cannot keep up with the number of patients that need care.
Boarding makes existing challenges worse.
- The stress of the job, the pandemic experience, rising incidence of violence, and many other factors all impact the mental health of emergency care teams.
- Piling on the strain of boarding means that emergency physicians are forced to manage stress that goes far beyond typical practice.
- The job is already challenging; emergency physicians have the highest rate of burnout among all physician specialties, according to Medscape’s 2022 Physician Burnout and Depression report.
Multifactorial Causes Require Systemwide Solutions
There are many contributing causes of boarding and no single solution. Staffing shortages and burnout exacerbate the crisis and perpetuate a dangerous and sometimes deadly cycle.
- ACEP and more than 30 organizations have written a letter to the White House, calling for a summit of stakeholders across health care to identify immediate and longer-term solutions to the nation’s urgent boarding crisis.
- Emergency physicians also support a bipartisan bill in Congress that would help address causes and consequences of boarding:
- The Improving Mental Health Access from the Emergency Department Act (H.R. 1205/S. 2157) would fund community efforts to implement and expand programs that help make sure that people in mental health crisis receive follow-up care.
- The consequences of boarding may play out in the emergency department, but institutional challenges require systemwide solutions.
