Revised September 2018
Reaffirmed October 2017
Originally approved January 2011
Many emergency departments experience critical overcrowding and heavy emergency resource demand, which hampers the delivery of high-quality medical care and compromises patient safety. (Chalfin DB, Trzeciak S, Likourezos A, et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007; 35(6):1477-1483).
In order for emergency departments to continue to provide quality patient care and access to that care, ACEP believes a “boarded patient” is defined as a patient who remains in the emergency department after the patient has been admitted or placed into observation status at the facility, but has not been transferred to an inpatient or observation unit.
The primary cause of overcrowding is boarding: the practice of holding patients in the emergency department after they have been admitted to the hospital, because no inpatient beds are available. This practice often results in a number of problems, including ambulance refusals, prolonged patient waiting times, and increased suffering for those who wait, lying on gurneys in emergency department corridors for hours, and even days, which affects not only their care and comfort but also the primary work of the emergency department staff taking care of emergency department patients. When EDs are overwhelmed, their ability to respond to community emergencies and disasters may also be compromised.
The time at which boarding starts, or the time-zero, is the time at which the decision has been made to admit or place the patient into observation status.
Reducing the time that patients for whom an “admit” or "observation" decision has been made remain in the emergency department (ED) can improve access to treatment and increase quality of care. ACEP agrees with the National Quality Forum deliberations noting the importance of examining the median time from admit decision time to time of departure from the ED for patients admitted to inpatient status:
A proxy for emergency department crowding includes the proportion and lengths of time patients remain in the emergency department after the decision to admit.6 Studies have shown that boarding patients in the emergency department can lead to greater hospital lengths of stay over prompt admissions.7,8 Reducing this time potentially improves access to care specific to the patient condition and increases the capability of facilities to provide additional treatment. (NQF: National Voluntary Consensus Standards for Emergency Care – Phase II:Hospital-based Emergency Care Measures, June 2008).
6 United States General Accounting Office GAO. Hospital Emergency Departments: crowded conditions vary among hospitals and communities. 2003; GAO-03-460.
7 Krochmal P, Riley TA. Increased health care costs associated with ED overcrowding. Am J Emerg Med. 1994;12:265-266.
8 Nawar ED, Niska RW, Xu J. National Hospital Ambulatory Medicare Care Survey: 2005 emergency department summary. Adv Data. 2007; (386):1-32.