The fight to reduce boarding begins with metrics and transparency. In Connecticut, we have passed novel legislation requiring hospitals to submit their boarding data and metrics to the state for public reporting. Although this does not fix the problem, it lifts the veil of secrecy and denial on the part of the government, administrators, and health systems. We need to highlight boarding as a patient safety and quality issue. Until hospitals and health systems are externally pressured to improve boarding, they will continue to follow the financial incentive of increased volume and decreased staffing.

The Leapfrog Group has already committed to making boarding part of their quality surveys, but this must only be the beginning. We need to expand our coalition and engage patients, communities, regulators, and even payers to hold hospitals responsible for deficits in emergency department capacity and boarding. This will not only improve patient experiences, but also our own workplace well-being.

Robert Hancock, DO, FACEP

Current Professional Positions: Emergency Physician, Elite Hospital Partners; Clinical Assistant Professor, Oklahoma State University Center for Health Sciences; Core Faculty, Comanche County Memorial Hospital Emergency Medicine Residency

Internships and Residency: Emergency Medicine Residency, UT Southwestern/Parkland Memorial Hospital (2004–2007); Chief Resident (2007)

Medical Degree: DO, UNT Health Science Center, Fort Worth, Texas (2004)

Response: Although boarding has been an issue since the beginning of our specialty, it has continued to worsen until it has become a crisis that threatens patient safety and adds unnecessary work and stress to a specialty that already has the highest rate of physician burnout.

During the COVID-19 crisis, boarding went from a longstanding dangerous practice to a crisis that compromised patient care and likely resulted in unnecessary morbidity and mortality. As emergency physicians, we quickly adapted and found new and innovative ways to continue to move patients through overwhelmed and saturated emergency departments. Unfortunately, many hospitals saw our innovation as a new solution to an old problem. Rather than working to resolve the root causes of boarding, they began to simply demand that we continue to do “more with less.”

ACEP needs to continue to lobby for legislation that directly addresses boarding by developing systems to streamline transfers and direct EMS traffic to less saturated facilities when possible. We can utilize artificial intelligence to power these systems so bed status and patient volumes can be updated in real time. Additionally, legislation is needed to address the lack of psychiatric facilities, which has created a crisis of psychiatric holds languishing in emergency departments for days and weeks. ACEP must continue to work with CMS to re-establish boarding as a quality metric with real-world ramifications and offer solutions for poorly performing facilities. Boarding is a complex issue and ACEP must continue to look for new and innovative ways to address this decades-old issue.