"We are an essentially freestanding ER and have about eight beds with one trauma/resuscitation room. Normally transfers for higher level of care would be completed within a few hours. We typically transfer patients to one of two larger institutions. We are now boarding patients on average ~48 hours. This has severely compromised our care for our sickest patients. Because of the delays, we are having patients leave against medical advice that truly should be admitted to the hospital. The delays in care are hampering our ability to care for a vulnerable population of people in our small community."