It’s Time To Totally Re-Think Boarding Patients In The Emergency Department

ER boarding occurs when a patient in the emergency room gets admitted to the hospital but there are no inpatient beds available, so the patient stays in the ER. This is problematic on many levels – the ER physicians hate it, the hospitalists hate it, the ER nurses hate it, and the patients hate it. I propose some solutions, that as an employed hospital medical director I could never propose without incurring the wrath of the medical center CEO, but now that I am retired and no one can fire me, I’m free to speak my mind.

• Boarding inpatients in the emergency department is unsafe and creates dissatisfaction for physicians, nurses, and patients
• The current ER boarding crisis in the U.S. is due to a combination of financial pressures for hospitals to maintain higher occupancy rates combined with a reduction in the number elective (as opposed to emergency) hospital admissions
• There are 9 specific steps that hospitals can take to reduce ER boarding or at least make boarding less unpleasant for patients
• There are 7 regulatory steps that would reduce ER boarding

ER boarding is a 21st century problem. In the past, hospitals kept a lower occupancy level of around 80% or so, meaning that there were almost always empty beds to put patients in who were admitted from the emergency room. Moreover, prior to 1990, elective hospital admissions made up a large percentage of the total number of admitted patients and if the hospital got full, you could always postpone an elective admission for a day or two.

Today, financial pressures have caused hospitals to maintain much higher occupancy levels, often around 90-95% – it is too expensive for hospitals to have empty beds and too expensive to pay nurses who have no patients to take care of. All it takes is a minor surge in the hospital census and the hospital has no empty beds to put emergency department admissions into. Furthermore, elective admissions are largely a thing of the past – surgeries are increasingly done in outpatient settings, patients get treatments such as chemotherapy in outpatient settings, and patients with illnesses that were once managed as inpatients are now managed as outpatients. For most hospitals, the emergency department has now become the hospital’s de facto admissions office. The result of these factors has been a reduction in U.S. community hospital inpatient beds from 3.3 per 1,000 population in 1995 to 2.4 per 1,000 population in 2019.

Respiratory illness admissions are more common in the winter months, correlating with the seasonal spike in influenza, RSV, and now COVID viral infections. These viruses can not only cause lung disease severe enough to warrant inpatient admission by themselves, but they are also important triggers for secondary bacterial pneumonias, COPD exacerbations, and asthma flares that can require inpatient treatment. Interestingly, there is also a seasonal variation to cardiovascular admissions, with more admissions in the winter months. As a hospital medical director, I always feared January because that was invariably the month that we would run out of inpatient beds.

When there are no inpatient beds, you can’t just send sick patients home, they end up stacking up in the emergency department. When the ER gets full, it goes on “divert status”, meaning that emergency squads and ambulances are diverted from the hospital’s ER to another hospital further away. When all of the ERs in a geographic region are full, the area goes on “regional divert”, meaning that the emergency squads arrivals are spread out to all of the hospitals’ ERs sequentially: 2 for hospital A, then 2 for hospital B, then 2 for hospital C, etc. In other words, the pain is spread out equally among all of the area hospitals.

This reached a boiling point recently at a hospital in my community where a patient became angry at being held in the ER because there were no inpatient beds. He became belligerent and made death threats to the ER nurses. When hospital security arrived and restrained the patient, they found a loaded firearm in the patient’s coat. The nurses have now lodged a complaint with the Ohio Bureau of Worker’s Compensation against the hospital.

Emergency rooms are not the place for inpatients

The emergency room is not a good substitute for an inpatient hospital room for a number of reasons:

• The bed in the ER is generally a gurney and not a regular hospital bed. Gurneys are uncomfortable and not conducive to sleep.
• The ER rooms do not have windows, private bathrooms or showers. No inpatient wants to have to walk down a crowded ER hallway every time they need to use the bathroom. Nor do they want to go for days without a shower. The absence of windows to the outside eliminates natural light that throws off circadian rhythms and fosters “sundowning” in older patients.
• Family visitation is different. Patient visitation is relatively easy and unrestricted in inpatient nursing units. Visitation in emergency departments is much more restrictive. Visiting family members must go through metal detectors and wait in the ER lobby until they are escorted to the ER room by a nurse. The result is that patients feel isolated.
• The food is different. In the ER, patients can usually get snacks and coffee but in an inpatient ward, the hospital’s dietary department will allow patients to choose their meal and get a scheduled hot breakfast, lunch, and dinner. In the ER, if a patient wants a full meal, they often have to have a family member bring it to them from home or from a nearby fast food restaurant.
• The ER is noisy. If you don’t believe me, stand in the middle of an emergency department for 15 minutes and then go stand in the hallway of an inpatient ward for 15 minutes. The noise in the ER is constant, loud, and inescapable for patients boarding in the ER. This can not only interfere with the patient’s ability to sleep but is also unnerving.
• The ER nurses are not inpatient nurses. Don’t get me wrong. ER nurses are great at what they do. But inpatient nurses are trained to take care of inpatients and are better at it than ER nurses.
• Case management is different. Many ERs will have their own case management staff and social worker. However, they are experienced in the needs of patients being discharged from the ER and do not regularly deal with the discharge needs of inpatients such as setting up home health and arranging transfer to skilled nursing facilities. As a result, boarded patients can have longer lengths of stay and may have less than ideal post-hospital care.
• The ER doctors are not hospitalists. Like ER nurses, ER physicians are great at taking care of emergencies. But they are not trained in management of inpatients. Moreover, they are constantly setting their priority for the new life-threatening problem that just rolled through the ER door – the admitted patient who is not actively dying gets pushed to a lower priority.
• Patients do not get good hospitalist care. When an ER patient get admitted, that patient then becomes the responsibility of the hospitalist who admits that patient. But if that hospitalist has 1 patient boarding in the ER on the first floor of the hospital and 12 patients in an inpatient unit on the eighth floor of the hospital, that hospitalist is going to spend the overwhelming majority of the workday on the 8th floor. The ER boarder will be out of sight, out of mind.
• It is even worse for ICU patients. Separating critically ill patients from the intensive care unit for hours or days removes them from the infrastructure of the ICU – they get less attention from the critical care nurses, critical care physicians, and respiratory therapists. Patient:nurse ratios in the ICU are typically either 1:1 or 2:1 and these ratios cannot be maintained by ER nursing staff.
• Boarding burns out staff. Having to care for patients under sub-optimal conditions is a perfect recipe for burnout of physicians, nurses, and other hospital staff. When staff experience burnout, it spreads through the hospital like an infection and can lead to long-term damage to the hospital and its ability to provide standard of care.
• Patient satisfaction suffers. Hospital administrators carefully monitor their hospital’s patient satisfaction scores. These scores are derived from surveys sent to discharged patients after hospitalization. Americans are increasingly weary of being over-surveyed by everyone and anyone they do business with. Consequently, many people are only motivated to respond to surveys when they are particularly angry and nothing makes patients more angry and dissatisfied than spending a day or two boarding in the ER.
• Hospitals lose money on inpatients boarding in the ER. A study published last October found that the hospital costs to care for stroke patients boarded in the emergency department was double the costs to care for these patients in normal inpatient nursing units. Because hospitals are paid a fixed amount based on the patient’s DRG, these additional costs are absorbed by the hospital and not the patient or the patient’s insurance company.

So, how do hospitals fix the problem?

As with most problems in healthcare, there are several solutions. Some are under the control of the individual hospital but others will likely require state and/or federal regulations. Here are specific measure that hospitals can take:

1. Hospitals need to track their daily census by month. Physicians all know that hospitals fill up in January and February but hospital executives need data in order to take action. It is not enough to simply track the number of admissions because this tell you nothing about whether those admitted patients were in the ER for several days or actually made it to an inpatient hospital room. If you can show the hospital administration that the hospital averages 95% capacity in January and 90% capacity all of the rest of the year, then that tells them that the hospital needs to have more available inpatient beds in January. In addition, tracking the total number of boarding hours by month can help demonstrate month-to-month variation in the number of staffed inpatient beds needed.
2. Hospitals need to track ER divert hours by month. When the inpatient beds fill up, then admissions back up in the ER and eventually, the ER fills up and has to go on divert status. When emergency squads are diverted to other hospitals, all of those financially lucrative hip fractures and myocardial infarctions are going somewhere other than your hospital. ER diversion is deadly to hospital finances. If you show the hospital’s administration that ER diversion hours increase every January and February, then that tells them that the hospital needs more capacity in the winter.
3. Hospitals need to track their nursing staff sick call-offs by month. Not surprisingly, nurses and other hospital staff get seasonal viral infections just like the patients. When the nurses (or their school-age kids) get sick, they call off work and hospitals restrict their admissions because they don’t have enough nurses to take care of all the inpatients. If you can show the hospital administration that nursing sick call-offs increase in the winter, you can argue for annually bringing in seasonal staff. This could be in the form of traveling nurses, contingent staff, or part-time employees. This must be done proactively – if you wait until a bunch of nurses are off work sick, then there is not enough time to recruit traveling new traveling nurses or contingent workers.
4. Re-engineer the ER rooms. If you must board inpatients in the emergency department, you have to renovate the rooms. That means having a TV for the patient to watch and a door to the room (not just a curtain) to reduce noise.
5. Better beds. No admitted patient should have to spend their hospital stay on a steel gurney. Hospitals need to have enough regular hospital beds so that when a patient is admitted, they get a comfortable hospital bed, even if they are in the ER.
6. Food services. Inpatients boarding in the ER should have the same meal selections as inpatients in an inpatient nursing unit. And those ER boarders should get their lunch at lunchtime and not at 4 o’clock PM when the patient finally had to ask specifically to get something to eat.
7. Hospitals should prepare to flex up the number of staffed inpatient rooms in the winter. For a large hospital, this could mean having a nursing unit that you only open up during winter. For a small hospital, this could mean closing off a few inpatient rooms from one nursing unit during the spring, summer, and fall so that those rooms could be activated during the winter.
8. Hospitals need to maintain a constant ratio of inpatient to ICU beds. If the hospital has a 20:1 inpatient to ICU bed ratio in the summer and then flexes up the number of staffed inpatient beds in winter, there needs to be a proportionate increase in staffed ICU beds in the winter. Many hospitals need to increase the number of ICU beds proportionate to inpatient hospital beds in winter – in the U.S., mortality from respiratory infections and heart disease is highest in winter whereas mortality from accidents, suicide, and homicide are highest in summer. Thus, many hospitals need to increase their staffed MICU (medical ICU) beds in winter and then increase their staffed SICU (trauma/surgical ICU) beds in summer.
9. But it is not just the physical rooms, the hospital needs to have more available nurses and hospitalists in the high census months. To ramp up the number of nurses in the winter, you have to get seasonal contracts out in the summer. The hospital simply cannot budget a fixed number of nurses for the entire year – plan to have more nurses available in the winter (or when your hospital’s data indicates you are most likely to have patients boarding in the ER). When hospitals do their annual budgets, they normally plan for a certain number of nursing FTEs for the entire year – this is a recipe for failure. Instead, determine how many nursing FTEs you need for each season (or better yet, each month) – if your hospital needs 500 nurses from March through November, you may very well need 530 nurses every December, January, and February. If there are 8 daytime hospitalists per day in summer, you may need 9 in winter. One option is to write hospitalist contracts so that the hospitalists do 12 shifts/month in the summer and 18 shifts/month in the winter.

We need additional regulations

Hospitals cannot fix the ER boarding problems by themselves. No matter how much data a hospital generates about seasonal variations in ER boarding, inpatient census, and ER diversion, there will inevitably be unexpected surges in inpatient admissions. You just can’t plan when patients are going to get medical illnesses.

The problem is that hospitals view patients in their ERs as hospital property. The hospital does not want to have to turn away a financially lucrative hospital admission and send that admission to the competing hospital on the other side of the town. I propose some regulations (as much as I normally hate regulations) to address the problems that hospitals cannot fix by themselves:

1. A Medicare requirement that if a Medicare patient boards in the ER for more than 8 hours, that patient must be offered the option of being transferred to another hospital. The 8 hour number is pretty arbitrary – pick another number if you prefer, maybe 12 hours or 4 hours (the Joint Commission considers boarding longer than 4 hours to be a safety risk). But put the pressure on the hospital to take the measures listed above to avoid ER boarding. If the hospital has to offer the patient transfer and the patient agrees to be transferred, then the hospital loses the revenue from that admission (and has to cover the cost of transport). If the patient doesn’t want to be transferred, then let them stay in boarding status, but at least empower them to be part of the decision making. Nothing motivates the hospital administration more than losing revenue.
2. A Medicare (or state department of health) requirement that hospitals make real-time information on ER boarding available on their websites. A patient who is trying to decide which ER to go to should be able to easily determine which hospital is currently at capacity. Even patients loyal to one hospital will often go to a different hospital if they know that they will have to wait for 2 days in the ER in order to get placed in a regular inpatient room. A shopping mall here in Central Ohio has several parking garages and at the entrance to each one, there is an electronic sign displaying the number of parking spaces that are available in real time. If parking garages can do it, then hospitals surely should be able to.
3. Eliminate current barriers to inpatient discharges. First, the Medicare “3-day rule” needs to be eliminated – this rule requires a patient to be a hospital inpatient for at least 3 days before that patient can be transferred to a skilled nursing facility. Second, Medicare Advantage Plan commercial insurance companies should be mandated to either approve or deny transfers to skilled nursing facilities within 24 hours of a hospital’s request to transfer – currently approval can take days, particularly if the request for transfer occurs on a Friday or a weekend day. If the federal government cannot change these regulations, then governors or state health department directors should be empowered to temporarily lift the Medicare 3-day rule and temporarily pause insurance company prior authorization requirements to send patients to skilled nursing facilities when there is a state-wide hospital census crises.
4. Require Medicare Advantage Plans and commercial health insurance companies to cover out-of-network hospitals and their physicians as if they were in-network when the regular in-network hospitals are full. Commercial insurance companies, and in particular Medicare Advantage Plans, generate profit by creating a narrow in-network list of hospitals and physicians. When patients are admitted to other hospitals or are seen by other physicians, the hospital and physician charges are considered out-of-network and are either not covered at all by the insurance company or only partially covered with the patient being responsible for a large portion of hospital/physician charges. Currently, patients cannot be transferred to out-of-network hospitals, even if the out-of-network hospital has the only available inpatient beds in the region. When in-network hospitals are all full, insurance companies should be required to cover hospitalization at out-of-network hospitals.
5. Unions need to be involved in solutions. Despite what union leaders will often say, a union has only one mission – to protect the interests of the union members. The union does not exist to protect customers, patients, or society in general. Most hospitals have staff that are unionized, whether that means housekeepers, nurses, or even doctors. Union contracts frequently limit what the hospital can and cannot do during episodes of overcrowding. Union contracts, and most importantly nursing union contracts, must be written with acceptable compromises for utilization of staff during times of hospital crowding.
6. Relax state laws requiring “certificates of need” for hospitals to open additional inpatient beds. In many areas, hospitals that are at maximum capacity cannot open additional beds because they are unable to get the necessary legal approval to do so. These state regulations exist to prevent one hospital from enlarging so much that it puts all of the other competing hospitals in the region out of business, kind of like when Walmart moves into a town and puts most of the small independent retailers and grocery stores out of business. But overregulation can pose a barrier to creating sufficient hospital bed supply in communities, with the result that the public is harmed.
7. Create a nationwide temporary state licensure for nurses and doctors who hold active nursing and medical licenses in other states. Currently, it can take weeks or months to get a nursing or medical license in another state. When a hospital has a sudden need for additional nurses or hospitalists, that hospital should be allowed to bring in nurses and doctors holding valid licenses to practice in other states for a temporary period before requiring a full in-state nursing or medical license. Three months would seem like a good time limit. Think of this as analogous to driver’s licenses – I can use my U.S. driver’s license in Ireland for up to 12 months – after that, I would need to get an Irish driver’s license. This temporary state licensure should also be extended to insurance plans with these physicians being automatically considered in-network physicians.

If hospitals were hotels…

Pull into the parking lot of just about any hotel off an interstate exit and you see a vacancy/no vacancy sign. And if you walk up to the registration desk of a hotel that is full, the clerk will not only tell you that they are full but that clerk will also likely give you a list of other nearby hotels and might even call around to help you find a room for the night. What the hotel would never do is tell you to wait in the lobby and on the chance that if someone checks out in the middle of the night, they’ll give you a room – otherwise you can sleep on the floor of the lobby. Why? Because that hotel is focused on customer satisfaction and knows that if they treat you well and help you find a room elsewhere for the night, you’ll leave feeling grateful and will likely come back to the hotel next time you need a room.

But I’ll bet you have never seen a “no vacancy” sign at a hospital. And if you walk into the registration office of a hospital that is boarding patients in the ER, I can almost guarantee that the registration staff will not call around to other hospitals to find you a bed. Hospitals need to take some lessons from the hotel industry. What hospitals don’t realize is that those patients who board for hours or days in the ER are going to leave the hospital unhappy. They are going to tell their family and friends how unhappy they were. And the next time they get sick, they are going to think very hard about going to a different hospital.

When the hospital CEO and CFO hear the words “The hospital is completely full”, they are happy because a full hospital is a profitable hospital. But for the rest of humanity, having the hospital completely full is a terrible thing to hear.

When the ER fills up with boarding inpatients, the hospital’s response to the doctors and nurses is often “Do the best you can because we can’t afford to open more beds“. When that happens, you need to offer to send the patient to another hospital… it is that simple. When boarding happens, bad things happen.

February 3, 2025