But conflicts in the definitions have arisen. What was the most important conflict? It was around the time stamp for the decision to admit or decision to transfer. Systems can choose to use a marker specific to the emergency physician, to the admitting physician, to the nursing process (e.g., the bed request, bed coordinator notification, or patient acceptance by the inpatient unit coordinator). It can induce a processing time factor of an hour, or two hours, or four hours, after the documented time the decision to admit occurred. That can artificially erase a significant time interval in the patient’s ED stay and appear to outside observers that the processing of inpatients is occurring in a shorter period of time.

In 2013, when hospitals were required to report ED boarding time—ED-2—to CMS and post it on the Hospital Compare website, patients could better understand the efficiency of hospital operations, no matter the size or complexity of the hospital. A lower time number was better and would mean that patients would not spend extra time in the ED once the decision was made that inpatient services were needed. Changing the definition of decision-to-admit would allow hospitals to report a shorter boarding time, with outside stakeholders unaware. Conversely, emergency physicians would be portrayed as less efficient, because the later time mark would appear to make the door to decision time interval longer, as though we were less capable.

ED Boarding Times, Trends, and Impacts

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The EDBA performs an annual data survey, and in 2024 that survey collected performance measures for 1,148 full-service EDs that saw 49 million visits. The data in Graph 1 show that boarding time increases with the volume of patients at the facility. High volume and adult-serving EDs have seen persistently high boarding times, which have resulted in long processing times across all ED patients, dissatisfied ED staff members, and high ED walkaway rates.

As reflected in Graph 2, the data for 2024 show that EDBA members have reduced length of stay for admitted patients, especially in EDs with volumes under 40K. The median boarding time across all EDs has been reduced to numbers that match 2014 and are markedly better than median boarding times reported in 2021 and 2022.

The lengthy boarding of admitted patients in 2021 and 2022 was crippling to the operations of many EDs in the country, producing significant stress on patients, staff, and ED operations. Smaller volume EDs have been more successful in reducing boarding impacts and reducing left-before-treatment-complete rates.