It’s a crisis hiding in plain sight in most hospitals: An analysis of more than 46 million US hospitalizations laid bare how deeply entrenched emergency department (ED) boarding has become.

At the peak in January 2022, 40% of admitted patients boarded in the ED for more than 4 hours, and 6% stayed longer than 24 hours — far beyond the Joint Commission’s patient-safety benchmark, according to the analysis published in the June issue of Health Affairs. Once considered a temporary symptom of pandemic-era capacity strain, prolonged boarding has since evolved into a defining feature of hospital operations nationwide.

“For hospitalists, that backlog creates a harsh domino effect,” said Elizabeth Rubin Ribak, MD, clinical advisor at The Embers Treatment Center in Phoenix. “By the time boarded patients reach us, they’re often sicker and more deconditioned. That directly translates into more complex care and less time for others.”

The data, from 2017 to 2024, underscored what frontline clinicians already knew: The ED had become the overflow valve for a health system operating at the limits of its physical and human capacity. Boarding was no longer a brief inconvenience but a chronic bottleneck that eroded patient safety, clinician morale, and care coordination.

The Numbers Behind the Backlog

The team behind the above-referenced study, led by Alexander Janke, MD, MHS, a clinical assistant professor of emergency medicine at the University of Michigan Medical School, Ann Arbor, Michigan, analyzed data from 1500 hospitals within the Epic Cosmos database, which contains de-identified records from more than 270 million patients across all 50 states and Washington, DC, representing roughly one third of all US hospital-based EDs.

Boarding increased every year surveyed, with the steepest rise occurring after the start of the COVID pandemic. The researchers found that boarding longer than 24 hours, once rare, had become routine, particularly in the Northeast, where rates reached 8% in winter peaks. Black and Hispanic patients experienced disproportionately longer boarding times, reflecting systemic inequities that extended beyond hospital walls.

The study team warned that extended boarding was not just an operational issue but also a signal of sustained hospital capacity strain. In the report, they called it a “critical indicator of system stress” that might foreshadow worse outcomes in future public health emergencies.

Ribak said the downstream effects for hospitalists were clear.

“Longer boarding times and holding in the ED lead to higher mortality, longer lengths of stay, and greater readmission risk,” she said. “It also compresses staffing schedules. When admissions are delayed, discharges happen later, and everyone’s workload peaks at the same time.”

Inside the Bottleneck: A View From the ED

For Susan Promes, MD, chair of the Department of Emergency Medicine at Penn State Health Milton S. Hershey Medical Center in Hershey, Pennsylvania, the issue is top of mind on a daily basis. Promes said it’s not the responsibility of the ED alone. 

“ED boarding is a systemic problem,” she said. “It’s tied to nursing shortages, limited behavioral-health facilities, and lack of post-acute placements. We’re not building hospitals for the patients we actually have.”

Hospitals face misaligned incentives that make it harder to move patients through, often stemming from reimbursement structures, administrative delays, or lack of post-acute resources that prevent timely admissions and discharges, Promes said. She said that in some cases, the problem is simply timing: weekend or after-hours gaps in insurance processing and facility availability left patients waiting for days, tying up beds and staff.

“For example, an elderly patient who has fallen repeatedly may need therapy or placement in assisted living,” she said. “But if insurance won’t reimburse the admission while that’s arranged, they sit in our emergency department for days. If someone comes in on a Thursday and we can’t get their paperwork processed, they might be here until Monday. Meanwhile, those beds and staff are tied up.”

Boarding exacts a psychological and professional toll on all involved, Promes said.

“You walk in ready to care for patients and are told there are no rooms and no nurses. That’s not how anyone wants to practice medicine,” she said. “We do the best we can, but some patients are in chairs instead of rooms because that’s all we have. It’s demoralizing for clinicians and frustrating for patients.”

Ribak agreed that the effects rippled beyond logistics.

“This goes beyond operations,” she said. “It impacts the psychological health of patients, medical staff, and hospitalists. Frustration from system inefficiencies leads to moral distress, reduced job satisfaction, and higher turnover.”

Promes said the challenge was not unique to her institution.

“Nationally, we’re seeing this everywhere,” she said. “Some hospitals are keeping patients in hallways on the inpatient floors to relieve pressure on the ED. That’s not ideal either, but at least it recognizes that this is a hospital-wide issue, not just an emergency-medicine issue.”

Ending the Bottleneck

On the day she spoke with Medscape Medical News, Promes’ dashboard showed boarding in her ED at one patient, down from 20 earlier in the fall. Promes said Penn State Hershey is “doing a lot of things right” and shared some of what the hospital has done to mitigate boarding issues.

“Our institution literally tracks and reports boarding every day,” she said. “Every morning, I get an update on how many admitted patients are boarding in the ED. If numbers are high, the chief nursing officer, administrators, and I huddle to find solutions before closing any units.”

A study on the issue published in the August 26 issue of Health Affairs Scholar echoed the importance of measurement and data visibility. The study team, led by Dahlia Rizk, DO, MPH, of Mount Sinai Health System, Icahn School of Medicine, New York City, went on to state that “sharing data about bed availability within a geographic region is one approach to identifying options for redistributing patients when ED boarding is high in a particular hospital.”

Overall, Promes said the hospital’s approach to ED boarding reflects a broader commitment to transparency and cross-department coordination.

“We’ve improved discharge timing, increased collaboration between hospitalists, case managers, and social workers, and made bed flow everyone’s responsibility,” she said. “It’s not perfect, but it’s progress.”

She said that loosening ED bottlenecks requires cultural and structural change, starting with how hospitals make decisions about patient flow.

“When there are challenges related to bed placement or staffing, those decisions shouldn’t happen in silos,” she said. “They should come from a group huddle that includes physician leaders, nursing leaders, and administrators. Our responsibility is to keep beds open when patients are waiting to be seen.”

She emphasized empowering frontline nurses while also maintaining coordinated oversight.

“Nurses have the clearest view of what’s happening in real time,” she said. “But we need shared accountability. You don’t close a bed when patients are waiting. Those decisions should always be made in collaboration.”

Promes said that at Penn State, leadership across the hospital holds structured huddles each day to review capacity, staffing, and barriers to flow in addition to other issues. She said that these huddles are generally attended by departmental administrators, but for her part, if she has an issue, she doesn’t hesitate to attend personally to escalate the problem and get answers. Her team within the ED also huddles cross-functionally to counter challenges.

Multiple studies like those noted above, in addition to the frequently cited white paper on achieving better patient flow hospital-wide produced in 2020 by the Institute for Healthcare Improvement (IHI), emphasize the need for frequent cross-disciplinary and interdepartmental check-ins.

The IHI recommended the use of “hospital-wide patient flow planning huddles and real-time demand and capacity problem-solving.” The white paper’s authors went on to say that, much like Promes described, “Representatives from the ED, OR [operating room], ICU, and all inpatient units…[should meet] to develop a proactive plan focused on the specific actions needed to create enough capacity to meet the patient care needs that day.”

“It keeps communication alive,” Promes said. “Hospitals are living organisms — conditions change hourly, and we have to adapt in real time.”

Additionally, Promes said transparency is equally essential.

“We track and share our boarding data openly with leadership and staff,” she said. “Transparency about workload and capacity helps everyone understand the strain and focus on solutions instead of blame.”

“Hospitals should be required to report how long admitted patients remain in the ED,” she said. “CMS [Centers for Medicare & Medicaid Services] already tracks outpatient wait times through the OP [outpatient place of service]-18 measure. We need something similar for admitted-patient boarding. We can’t fix what we don’t measure.”

OP-18 is a CMS quality metric, part of its Outpatient Quality Reporting program. This particular metric indicates the median time from ED arrival to ED departure for discharged patients.

Promes’ argument that transparency — particularly the public reporting of ED throughput and boarding data — would help drive accountability and accelerate improvement is substantiated by extensive federal analyses. As the Agency for Healthcare Research and Quality noted in its 2024 Emergency Department Boarding Summit Report, “Standard setting, measurement, and public reporting of measures comprise a suite of tools that have long been used to leverage improvement in the US healthcare system.”

The Road Ahead

Promes said she remains hopeful that awareness and data transparency will continue to move the issue forward.

“Every hospital leader I know understands that boarding is not sustainable,” she said. “We need to look at the system as a whole — from inpatient staffing to long-term care access — and treat it like the emergency it is.

“We owe it to our patients to figure out how to make this better,” Promes said. “We went into medicine to care for people, not to watch them wait.”

Promes reported receiving royalties from McGraw Hill Education for textbooks she has served as editor of in the past. She reported receiving an honorarium from the Society of Academic Emergency Medicine (SAEM) for her role as editor-in-chief of Academic Emergency Medicine Education and Training. She reported receiving compensation for travel expenses and an honorarium from the American Board of Emergency Medicine for serving as a test writer and examiner. She reported being a board member for PPI, the SAEM Foundation, and the Association of Academic Chairs of Emergency Medicine and being compensated for travel.

Ribak reported having no disclosures.