Boarding of Admitted and Intensive Care Patients in the Emergency Department

Revised February 2023, June 2017, April 2011, April 2008, January 2007

Originally approved October 2000 


Optimal utilization of the emergency department (ED) includes the timely evaluation, management, and stabilization of all patients. Once admitted, patient care is most effectively and safely delivered on inpatient units. Boarding of admitted patients in the ED represents a hospital-wide failure and contributes to lower quality of care, decreased patient safety, reduced timeliness of care, reduced patient satisfaction, an increased number of patients leaving without being seen, and increased mortality. Additionally, it directly contributes to ED crowding due to the resultant loss of bed and resource capacity. ED crowding and its negative impacts on patients are due to misaligned health care economics and financial pressures on hospitals. As ED boarding is a hospital-wide problem, ED leadership, hospital administrators, EMS directors, community leaders, state and federal officials, hospital regulators and accrediting bodies must work together to find solutions to this problem. In order for the ED to continue to provide accessible and high quality patient care, the American College of Emergency Physicians (ACEP) believes that:

  • Hospitals bear the responsibility of ensuring the prompt transfer of admitted patients to inpatient units as soon as the disposition decision by the treating emergency physician has been made. Additionally, in the event of ED boarding, hospitals must have established over-capacity contingency plans in place.
  • ED patient boarding leads to quality and patient safety issues as well as impacts physician and staff wellness and retention. If transfer of admitted patients to inpatient units is delayed, the hospital must provide the supplemental nursing staff necessary to care for the patients boarded in the ED.
  • Admitted patients should receive the same level and quality of care regardless of location. The admitting physician (or designee) is responsible for ongoing care of the patient after accepting responsibility for the patient’s care whether verbally, by policy, or by writing admission orders, regardless of the patient’s physical location within the hospital. The emergency physician will always be available to respond to crisis for patients physically boarding in the ED in coordination with the admitting physician.
  • In the event that the number of patients needing evaluation or treatment in an ED is equal to or exceeds the ED’s treatment space capacity, admitted patients should be promptly distributed to inpatient units regardless of inpatient bed availability, for example, to inpatient hallways.
  • Hospitals should have staffing plans in place that can mobilize sufficient health care and support personnel to meet increased patient needs.
  • Hospitals should develop appropriate mechanisms to facilitate availability of inpatient beds, nursing staff, and support personnel to meet the increased patient needs in the event of ED boarding.
  • Emergency physicians and emergency medicine leadership should be involved in the hospital-wide efforts aimed at monitoring and improving inpatient resource utilization.
  • Nurse staffing patterns applicable to other specialized areas/units of the hospital should apply equally to the boarded ED patients to assure that there is a consistent standard of care within the organization. These staffing patterns must not degrade the ability of the ED staff to provide emergency care and must be consistent with established guidelines.
  • Hospital diversion, as a temporary solution to ED boarding, should only be instituted if internal resources have been exhausted and outside community facilities have resources available to meet the needs of diverted patients. Additionally, all mechanisms for diversion must be consistent with ACEP policy on ambulance diversion.
  • Hospital regulatory and accrediting bodies should mandate standards for prompt transfer of admitted patients from the ED to inpatient units.

Hospitals should have established protocols and procedures related to the expeditious transfer of boarded patients to in-network facilities, outside hospitals, or alternative care settings with appropriate inpatient beds when none are available at the hospital of origin.

If psychiatric patients are boarded in the ED, either admitted for a psychiatric purpose or pending admission, the hospital must assure the same level of oversight and psychiatric care afforded to inpatient psychiatric patients.

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