U.S. Hospital Overcrowding in Emergency Departments: At Last, Some Necessary Intervention
If you or a family member has recently needed urgent hospital care, you might have found yourself spending hours, or even days, on a gurney in the emergency department (ED) before being moved to an inpatient bed. This is known as emergency department boarding, where admitted patients are held in the ED due to a lack of inpatient beds availability.
The emergency department boarding issue has been a persistent problem for three decades, but it has recently escalated to a crisis level. Not only does it make for an uncomfortable experience for patients, but it also increases medical errors and mortality rates. In fact, boarding is the main cause of ED overcrowding, leading to prolonged wait times for all patients, including those who require immediate care.
In addition, boarding contributes to healthcare professional burnout, further exacerbating the current staffing shortage in hospitals.
So, Why Is It Getting Worst?
Despite its long-standing recognition and the existence of potential solutions, market forces have failed to resolve the issue. ED boarding has become so common that it has even been discussed on Max's podcast, The Pitt, featuring Noah Wyle. Hospitals are financially motivated to remain full as inpatient admissions generate revenue, making it challenging for them to maintain the additional capacity needed to prevent boarding.
There are various underlying reasons for the escalation of boarding, such as nursing shortages hindering hospitals' ability to staff available beds. There has also been a decrease in inpatient hospital beds per capita due to cost-cutting measures. Lack of access to post-acute care, leading to delays in discharging patients who need rehabilitation or nursing home placement, is another contributing factor. Increased patient volumes, particularly from aging and chronically ill populations, have also resulted in increased demands on hospitals.
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One significant issue is the insufficient incentives for hospitals to enact effective solutions. However, there are signs of movement toward improved policies to address the issue.
Recently, a Health Affairs article by Dr. Chris Moore and Rebekah Heckman highlighted some of the progress being made in various areas.
A Shift Toward Transparency and Accountability
Government agencies have typically tracked ED boarding, but they stopped publicly reporting it in 2021. Now, efforts are underway to reintroduce public reporting of hospital performance.
In 2023, the Centers for Medicare and Medicaid Services (CMS) contracted with Yale University to develop the Equity of Emergency Care Capacity and Quality (ECCQ) measure. This measure will monitor certain indicators, such as:
- Patients waiting over one hour for a treatment space.
- Patients leaving without being seen due to excessive delays.
- Patients boarding over four hours when admitted.
- Total ED stays exceeding eight hours.
If CMS decides to publicly report this measure, it could become a powerful accountability tool, increasing national pressure to address the emergency care system's long wait times and other issues.
Some states are taking action more quickly than the federal government. Connecticut became the first US state to require all non-state-funded hospitals to publicly report their ED boarding times under Public Act 24-4 in 2022. Additionally, The Leapfrog Group will be incorporating ED boarding metrics into its hospital quality survey, which could affect hospital reputations and even reimbursement from insurers.
Financial Incentives and Penalties: A Stronger Motivator?
One promising approach is linking hospital payments to ED boarding metrics. Maryland is leading the way, incorporating ED boarding into its Quality-Based Reimbursement (QBR) program, with 2% of hospital revenue at risk. In 2026, hospitals with excessive boarding times will face financial penalties-approximately 0.2% of overall revenue.
These modifications are a step toward addressing the problem, but it remains unclear whether a relatively modest penalty will be enough to drive real change. Hospitals may opt to absorb the penalty instead of implementing major structural alterations. Further discussions in Maryland aim to increase financial rewards and penalties to provide hospitals with even stronger incentives.
A key question is whether other states-or even CMS at the federal level-will follow Maryland's lead. If hospital payments directly tie to ED boarding rates at the federal level, the pressure to solve the problem will increase substantially.
Beyond Regulation: What Else Can Be Done?
While transparency and financial penalties could encourage hospitals to reform, long-term solutions require operational changes that address the root causes of ED boarding. Hospitals need to implement strategies to improve patient flow, such as:
- Expanding inpatient staffing to ensure available beds are efficiently utilized.
- Optimizing hospital workflows to minimize inefficiencies, particularly as patients move between departments.
- Streamlining discharge processes to reduce delays in moving patients out of the hospital.
- Synchronizing elective surgical schedules throughout the week and even weekend to reduce inpatient bed demand fluctuations.
- Increasing collaboration with skilled nursing and rehabilitation facilities to expedite inpatient bed releases.
- Effectively utilizing observation units to manage patients who do not require full inpatient admission.
- Employing AI and real-time data analytics to optimize hospital bed management and pinpoint patient flow bottlenecks.
However, none of these solutions will work without adequate funding, support, and strong incentives to deploy interventions. Hospitals struggling with staffing shortages and financial pressures may find it difficult to invest in better systems, even if penalties or transparency measures push them in that direction.
The Path Forward
EDs serve as the backbone of America's healthcare safety net, but without systemic reform, patients will continue to endure long waits and boarding after being admitted to the hospital. While Maryland and Connecticut are paving the way at the state level, other states and federal agencies must take similar action.
With mounting pressure from lawmakers, regulators, and the public, the time for action is now. However, unless financial penalties are substantial, operational obstacles are addressed, and hospitals receive the resources needed to make changes, the emergency department boarding crisis will persist.
- The emergency department boarding crisis has led to increased mortality rates and prolonged wait times for patients, ultimately contributing to healthcare professional burnout and exacerbating the current staffing shortage in hospitals.
- Although various reasons underlie the escalation of emergency department boarding, insufficient incentives for hospitals to enact effective solutions and recent changes in government policies regarding public reporting have hindered progress.
- The Centers for Medicare and Medicaid Services (CMS) has recently contracted with Yale University to develop the Equity of Emergency Care Capacity and Quality (ECCQ) measure, which will monitor certain indicators related to emergency department boarding. If CMS decides to publicly report this measure, it could incentivize hospitals to address the problem and improve national emergency care system performance.
