ED Boarding – ACEP Now

In November 2022, the American College of Emergency Physicians sent a letter to President Biden on behalf of 34 organizations, asking to convene stakeholders to identify solutions to address the emergency department (ED) boarding crisis.1 The letter detailed ED physician stories, highlighting the preventable harms from boarding, crowding, long waits, staff shortages, burnout, and the disproportionate impact on behavioral health and pediatric populations. Hospital crowding and ED boarding have been longstanding and persistent crises for more than two decades, yet have progressively worsened over the COVID-19 pandemic.2

Early pandemic days brought uncertainty, personal risks to clinicians, and waves of COVID-19 patients. Over time, this caused attrition among ED physicians. Even more so, nurses left practice or migrated to non-hospital settings. There is no easy fix to the nurse-supply problem. A pre-pandemic analysis estimated a shortage of 500,000 registered nurses by 2030.3 Given the current attrition rate, this is most likely an underestimate. Today, many hospital inpatient units, EDs, and post-acute care locations cannot adequately staff due to nursing shortages. 

Emerging data on ED crowding are stark. Left without treatment (LWOT) rates increased from a median of 1.1 percent pre-pandemic (interquartile range (IQR), 0.5-2.5 percent) to 2.1 percent post-pandemic (IQR 0.6-4.6 percent).4 LWOT rates were as high as 10 percent in the 95th percentile. Internal data from US Acute Care Solutions EDs show similar trends, with progressively lengthening ED length of stay (LOS) and increasing LWOTs. Here’s what the government can do to impact the hospital crowding and ED boarding crisis.

Solution 1: Immediately reintegrate the admitted ED LOS measure into public reporting and Medicare stars for hospitals

Historically, hospitals measured and reported ED LOS for admitted patients, a proxy for the ED boarding time. The Centers for Medicare and Medicaid Services (CMS) developed and maintained the measure. It was submitted in 2008 to the National Quality Forum (NQF), which convenes external groups to endorse measures. NQF re-endorsed the measure in 2014. In November 2018, CMS withdrew the measure. NQF endorsement was removed. CMS used the following justification: “Costs associated with the measure outweigh benefit of its continued use in the program.”5 CMS also “… respectfully disagree(s) that the removal will result in hospitals not working to maintain low boarding time.”6

It’s time to bring the measure back. It should be publicly reported so patients can assess how long they might have to stay in the ED boarding prior to transfer to their inpatient bed. It should be included in Medicare star ratings for hospitals, which is a summary measure of hospital quality for consumers. The admission LOS measure formerly reported only the median time. Future versions should also report the 75th and 90th percentile times for full transparency. It should also differentiate boarding times for psychiatric patients, who are at high risk for very prolonged boarding. Public data on boarding times, ideally tied to hospital reimbursement, will help change the perverse financial incentive that hospitals make more money when they preferentially give beds to patients with lucrative scheduled procedures over ED patients.7