Building a public-private partnership to confront the emergency department boarding crisis

Abstract

The nation's critically crowded emergency departments have aptly been called “the sentinel canaries in the health care system,” given their nexus point between inpatient, ambulatory, perioperative, and long-term care systems. Emergency department boarding—holding or physically keeping a patient in an emergency department after the clinical decision to admit the individual to the hospital—is a critical symptom of overload and breakdown of the more extensive health care delivery system. Despite more than 25 years of incontrovertible scientific evidence that the practice is associated with significant harm, little progress has been made in confronting its structural and economic drivers at a national scale. This article, authored by federal health care leaders, opens the Health Affairs Scholar Featured Series by highlighting the importance of a public-private partnership approach and lays the foundation for a series that will further present a holistic evaluation of the topic, encouraging a multi-faceted approach toward resolving this critical health system issue.

The nation's critically crowded emergency departments (EDs) have aptly been called “the sentinel canaries in the health care system.”¹ Symptoms of systemic dysfunction are obvious in EDs, in part, because EDs provide 24/7 availability as a community safety net at the nexus point between inpatient, ambulatory, perioperative, and long-term care systems. Any one of us may need unscheduled, acute medical care at any time (on average, about 43% of people will need it any given year²). We each rely on the assumption that we will have timely, efficient, and consistent access to safe, effective, patient-centered care³ in a hospital ED 24 hours a day, 365 days a year. However, dysfunction across the health care delivery system holds that promise in jeopardy, in large part driven by ED boarding, the operational practice of holding or physically keeping a patient in the ED after the clinical decision has been made to admit the patient to the hospital for treatment.

ED boarding is predominantly a manifestation of patient flow dysfunction throughout the entire system and represents an outcome of incentives to deploy care delivery resources in a particular way. Thus, the term “ED boarding” is a misnomer since it describes where a hospital may elect to keep an admitted patient, but its causes and solutions lie far beyond the walls of the ED. We use the term as a convenient shorthand partly because of its consistent use in the scientific literature for many years. Yet, just as treating nausea that is the result of a migraine will not address the migraine itself, it is crucial to differentiate the location of the symptom from its root cause. In the case of ED boarding, the underlying drivers span the care delivery system.

Despite more than 25 years of incontrovertible scientific evidence⁴ that boarding admitted patients in EDs is associated with significant harm, little progress has been made in confronting its structural and economic drivers at a national scale. More than 600 articles specific to ED boarding are indexed in MEDLINE, and approximately 4000 evaluate the practice's broader persistent consequences of ED crowding. While the phenomenon is by no means new, the harms of boarding have been further entrenched both during⁵ and since⁶ the COVID-19 pandemic and are worse now than perhaps at any other time in the history of modern health care. As ED visits continue to increase nationally,⁷ these effects are likely to compound, both in their quality and safety impacts and expenditures.⁸ Reassuringly, however, this is a problem with known causes, and while solutions are not simple, they are within reach of stakeholders and actors across care systems.

In our roles as federal health care leaders, we feel uniquely privileged to frequently engage with people who feel these impacts directly and have the agency to implement needed improvements. While health systems science, policy, and regulatory experts have focused on ED boarding independently, this topic has yet to benefit from structured and cohesive collaboration among public sector agencies and myriad private partners and stakeholders. In this article, we will share more about that collaborative approach, the insights we have heard, and actions and levers for change. The Health Affairs Scholar Featured Series that will follow further dissects the impacts, theoretical framework, and literature to date and will provide critical evaluation and direction from various perspectives.

A critical patient safety and care quality issue

At least 16 studies have linked exposure to ED boarding to increased in-hospital mortality.^9-24 A large body of evidence has also shown that boarding is associated with longer in-hospital length of stay^{13, 21, 25-27} (further exacerbating hospital capacity problems), decreased patient experience and satisfaction,^28-34 increased risk-adjusted hospital spending,^35-39 and numerous non-fatal patient safety consequences. Boarding is associated with increased incidences of serious adverse events,⁴ including medication errors, misdiagnosis errors, readmissions and increased required intensity of care, hospital-acquired infections, delirium,^40-42 decline in functional status,⁴³ care nonadherent to evidence-based guidelines, violence against health care workers,⁴⁴ negative experiences in graduate medical education,⁴⁵ burnout, and moral injury.⁴⁶ Boarding also has a disparate impact⁴⁷ among pediatric patients, especially those with mental health crises,⁴⁸ older adults,^{24, 49-51} and other vulnerable populations at increased risk.⁵²

The fundamental driver of this intractable crisis appears rooted in the design of health care economic, policy, and regulatory structures that incentivize response to acute care demand by electing to keep admitted patients in emergency departments, rather than assess timing and capacity for elective surgeries, improve the efficiency of care for hospitalized patients, and expand opportunities for hospitals to discharge patients with complex post-acute care needs. Hospitals themselves experience a similar outflow obstruction, with delayed inpatient discharges often due to the considerable difficulty transitioning care of patients medically ready to leave the hospital.⁵³ Even a strong desire to protect patients from the known harms of ED boarding seems insufficient to overcome the current structural incentives to engage in the practice when hospital occupancy approaches or exceeds capacity.

ED boarding drives ED crowding

Solving boarding is the key to solving ED crowding more generally. Crowding in emergency departments is a broad outcome of demand-capacity mismatch for acute, episodic, and unscheduled care but is not actually a problem of emergency departments. While common for healthcare leaders and policymakers to erroneously think that high demand for unnecessary or low acuity emergency care is the cause of crowding, ED boarding has long been recognized as the dominant driver of ED crowding, forcing hospital-based emergency care to a breaking point.⁵⁴ Boarding admitted patients in EDs is a symptom of a systemic breakdown across the local health care delivery system, not caused by factors within any given ED (Figure 1).

The arc of federal partnership and leadership

Agencies of the United States Department of Health and Human Services (HHS) have long embraced the principle of public-private partnerships. They are highly engaged in charting a strategy to confront boarding as a critical daily crisis hospitals nationwide face. Federal partners have increasingly helped to catalyze work in this area for nearly two decades. The United States General Accounting Office examined ED boarding and its consequences in 2003.⁵⁵ AHRQ supported the 2007 Institute of Medicine (now National Academies) reports on the future of emergency care in the US health system⁵⁶ and published guides to help hospitals improve patient flow in 2011⁵⁷ and improve discharge processes in 2014.⁵⁸ CMS hosted its national Grand Rounds on boarding in March 2023⁵⁹ and a listening session on aligning incentives to reduce boarding at the May 2023 CMS Quality Conference.⁶⁰ In response to a letter from 44 bipartisan members of Congress,⁶¹ AHRQ was charged in December 2023⁶² to use its unique statutory authority to improve health care nationwide and its work with HHS partners to lead the Department's response. It convened a multistakeholder Director's Roundtable on ED boarding in May 2024. AHRQ also hosted a panel discussion at Academy Health in June 2024, and its work culminated most recently in the full-day AHRQ Summit To Address Emergency Department Boarding⁶³ at the headquarters of the US Department of Health and Human Services in October 2024 (more resources are also available on the AHRQ ED topic web page⁶⁴).

The AHRQ summit to address Emergency Department Boarding

With the charge that it is time to turn the current ED boarding crisis into an inflection point and to find real, implementable solutions, the October 2024 Summit convened approximately 100 stakeholders and experts in the Great Hall at the HHS Humphrey Building. Participants represented diverse perspectives, including patients, community organizations, professional associations, hospitals, physicians, nurses, economists, emergency medical systems professionals, researchers, clinical practice groups, accrediting organizations, payers, and state governments. Another 695 attendees joined the online livestream of the main session. In addition to leaders from AHRQ and CMS, multiple federal agencies were represented, including the Administration for Community Living, Administration for Strategic Preparedness and Response, Biomedical Advanced Research and Development Authority, Health Resources and Services Administration and its Federal Office of Rural Health Policy, and Substance Abuse and Mental Health Services Administration.

While we expect that complete proceedings of the Summit will be published by AHRQ in early 2025 and provide more details, it is crucial to highlight five domains that formed the basis for the Summit's afternoon breakout discussions and illuminate a potential framework for future areas of public-private engagement, including this Health Affairs Scholar Featured Series: (1) system-wide financial and regulatory optimizations; (2) real-time regional health system data, measurement, and metrics; (3) sustained workforce development, supportive technologies, and workforce safety; (4) rural dimensions, and (5) behavioral health connections.

System-wide financial and regulatory optimizations

Summit participants observed opportunities to enhance public reporting of specific measures, including those that focus on the protection of populations at increased risk (such as older adults, children, and patients with behavioral health needs), rebalance financial incentives, and increase transparency.

Real-time regional health system data, measurement, and metrics

Participants discussed automating the capture of patient flow data via integration with electronic health record platforms, obtaining high-resolution data on system capacity refreshed frequently, and considering the importance of trust in data interoperability and sharing standards.⁶⁵

Sustained workforce development, supportive technologies, and workforce safety

Participants described success stories around investment in workforce training and augmented or artificial intelligence to improve safety and reduce burden across the full spectrum of care.⁶⁶ Participants also discussed the importance of peer support and destigmatizing conversations about health care workers mental health and burnout.

Rural solutions

Participants discussed the unique challenges faced in rural facilities, where capacity constraints at larger hospitals limit outbound transfers and keep high-acuity patients boarding in facilities under-resourced to care for them. The conversation included ideas for regionalization, enhanced partnerships and coordination, and incentives to allow transferred patients to return to rural communities as soon as possible.

Behavioral health connections

Participants described avenues to expand further access to behavioral health care, including expanding awareness of primary care-behavioral health integration opportunities,⁶⁷ community-based mental health crisis centers, enhancing telehealth care, and improving follow-up efficiencies and care transitions (Figure 2).

Next steps for AHRQ and CMS

AHRQ's unique mission is to improve health care delivery in the United States. AHRQ's 1999 Congressional authorization requires it to produce scientific evidence and disseminate and implement “actionable knowledge” to enhance the experience and quality of care by making it safer, more accessible, effective, and affordable for all. AHRQ is tasked with accomplishing this daunting mission by working with other US Department of Health and Human Services divisions and external partners (i.e., health care systems executives, clinicians, accrediting bodies, and purchasers) to ensure the “actionable knowledge” is understood and used. Consistent with its authorization and mission, AHRQ will build on its work to date through the Health Affairs Scholar Featured Series which will provide context and actionable solutions in the framework described here. In addition, AHRQ can continue to use its authority to provide funding to support research in this area (including via a recent Special Emphasis Notice⁶⁸) and convene public and private partners to develop consensus on solutions further and address implementation barriers across the health care system.

CMS has an active internal ED boarding working group led by the Center for Clinical Standards and Quality in collaboration with AHRQ. CMS views ED boarding as threatening virtually every element of the CMS National Quality Strategy⁶⁹ and has comprehensive work underway to evaluate the reimbursement incentives that may exacerbate ED boarding as their unintended consequence and to identify policy levers to intervene. This work makes use of existing CMS authorities, such as those on quality measurement and reporting of access to emergency hospital care,⁷⁰ quality, safety, and oversight of hospitals through regulatory standards and survey program,⁷¹ the Acute Hospital Care at Home (AHCAH) initiative,⁷² adoptions of an age-friendly hospital measure beginning in CY 2025,⁷³ improvement of prior authorization processes and reduction of administrative burdens on the hospital discharge process,⁷⁴ and achieving innovative health system transformation through model design,⁷⁵ among many others.

Conclusion

Holding admitted patients in hospital emergency departments is an increasingly common (and untenable) response to care delivery systems struggling to match capacity to demand. It is increasingly common because a complex landscape of economic, policy, and regulatory structures have historically evolved in service of a scheduled, transactional, procedurally-focused care paradigm. However, we live in an era of increased patient acuity and medical complexity with more focus on value, more need for chronic disease management, and growing reliance on unscheduled care. Choosing to board patients in EDs is demonstrably associated with unacceptable adverse quality, safety, and financial consequences; yet, our collective desire to protect patients from harm has not proven sufficient to overcome the structural incentives that led to the practice. AHRQ and CMS have partnered with many public and private-sector stakeholders to turn the current crisis into an inflection point, most notably via the recent AHRQ Summit To Address Emergency Department Boarding. This Health Affairs Scholar Featured Series will further present a holistic evaluation of the topic, encouraging a multi-faceted approach toward resolving this critical health system issue. Much important work is ahead, and we invite all who have ever used—or may someday need access to—safe, high-quality acute care in the United States to join us in reimagining a collaborative path forward.

Acknowledgments

The authors acknowledge the valuable insights and collaborative support provided by former AHRQ Director Dr. Robert Otto Valdez on this issue and the expertise and tireless efforts of the team who planned and executed the AHRQ Summit To Address Emergency Department Boarding (especially Rachael Boicourt, Regina Smith, Dr. Robin Weinick, and Amy Rabin). This work would also be impossible without our federal colleagues’ support and leadership in evaluating many facets of this complex issue, especially Dr. Dora Hughes and Dr. Shari Ling.

Supplementary material

Supplementary material is available at Health Affairs Scholar online.

Funding

All authors are employed by their respective agencies of the federal government and performed the work in their official capacities.

Data availability

There are no new data associated with this article.

Notes

Author notes