The waiting room is already full when the next ambulance arrives.

Inside the emergency department, every treatment bay is occupied. Nurses move quickly between stretchers lining the hallway. A physician steps out of a room after placing admission orders for a patient with pneumonia; instead of heading upstairs to an inpatient unit, that patient remains in the emergency department.

The patient has nowhere else to go.

Down the hall, another patient with abdominal pain has been waiting for hours. Across the unit, an elderly patient admitted for heart failure boards in a curtained space while emergency staff work to stabilize new arrivals.

Scenes like this play out daily in emergency departments across the United States.

The practice is known as emergency department boarding—when patients who have already been admitted to the hospital remain in the emergency department because inpatient beds are unavailable elsewhere in the hospital.

For emergency physicians, boarding is more than a frustrating operational problem. Increasingly, experts view it as a warning sign that something deeper is wrong with the health system itself.

The RAND report, Strategies for Sustaining Emergency Care in the United States, suggests that boarding reflects structural pressures across hospitals, financing systems, and patient flow, which surface most visibly in the emergency department.

In other words, the emergency department is where the U.S. health care system’s failures become impossible to ignore.

A Symptom of a Much Larger Problem

Emergency physician leaders have been sounding the alarm about ED crowding for decades. Yet the issue remains widely misunderstood.

Dr. Kelen

Gabor Kelen, MD, FRCP(C), FACEP, professor and chair of the department of emergency medicine at Johns Hopkins Medicine and emergency physician-in-chief at Johns Hopkins Hospital in Baltimore, said the current conversation echoes warnings that have circulated throughout emergency medicine for years.

“There’s a sense that RAND has suddenly revealed that emergency medicine is in crisis,” Dr. Kelen said. “But the truth is, this alarm has been sounded for decades.”

National reports have warned about strain in emergency care for years, including the Institute of Medicine’s landmark 2006 report Hospital-Based Emergency Care: At the Breaking Point.

Despite repeated warnings, the conditions that produce boarding have persisted. One reason, Dr. Kelen said, is structural. Emergency medicine developed differently from many other hospital specialties. For decades, emergency physicians often worked as contracted services rather than fully integrated departments within hospital leadership structures.

“At its origins, emergency physicians were essentially delivered to hospitals in shifts,” Dr. Kelen said. “We weren’t always viewed as core institutional partners.”

That legacy still influences how boarding is perceived today. Too often, crowding is framed as an emergency department efficiency problem rather than a hospital-wide operational challenge. But many health system leaders now recognize that boarding reflects deeper structural issues.

Dr. Carr

Speaking at an Agency for Healthcare Research and Quality (AHRQ) summit on ED boarding, Brendan Carr, MD, MA, MS, chief executive officer and the Kenneth L. Davis, MD, Distinguished Chair of the Mount Sinai Health System and professor of emergency medicine at the Icahn School of Medicine at Mount Sinai in New York, said emergency clinicians often see those failures first.

“This community is not a bunch of emergency physicians pounding their fists on the table,” Dr. Carr said. “These are folks that can see the failed social policy and the chinks in the armor of the health care system and can help you to find not a magical silver bullet—there isn’t one—but a matrixed number of incentives and structural changes and transparency that can get us to a place where we have a health care system that we are proud of.”

The RAND analysis reinforces this framing: boarding is largely driven by system-level capacity constraints and financial incentives, rather than inefficiencies within emergency departments.

The Capacity Tipping Point

Understanding boarding requires looking beyond the emergency department to how hospitals manage capacity and financial incentives. Dr. Kelen compares hospital operations to highway traffic.

“When traffic is light, everything moves smoothly,” he said. “But once you hit about 85 percent capacity, there’s no margin for error.”

Hospitals function similarly. Research shows that when inpatient occupancy rises above roughly 85 to 90 percent, patient flow slows dramatically and boarding becomes far more likely.

Yet many hospitals routinely operate at or above those levels. Some large academic medical centers even operate effectively above 100 percent capacity, meaning more patients have been admitted than there are staffed inpatient beds available.

Financial incentives play a role in this dynamic. “Hospitals must stay full to survive financially,” Dr. Kelen said. “To do even that, they must prioritize high-margin elective patients and procedures. That inevitably pushes ED admissions to the back of the line.”

When inpatient beds are tightly managed around scheduled procedures and specialty services, patients admitted from the emergency department often wait hours or even longer before being moved upstairs.

The Hidden Harm of Boarding

To those outside emergency medicine, boarding may appear to be an inconvenience or operational bottleneck. Emergency physicians know the consequences can be far more serious.

Research has consistently linked prolonged boarding with delayed treatment, increased medical errors, longer hospital stays, and higher mortality rates.

But the harm often goes unrecognized.

“When something goes wrong on an inpatient floor, such as a surgical site infection or a catheter-associated infection, it’s clearly recognized as likely preventable,” Dr. Kelen said. “But when a patient deteriorates after hours of waiting in a crowded ED, it’s almost never labeled as preventable harm.”

Patients experiencing sepsis, stroke, or internal bleeding may wait longer for diagnosis or treatment as clinicians juggle a growing number of patients.

At the same time, clinicians face escalating workplace stress. Violence toward health care workers has increased in emergency departments nationwide, particularly since the COVID-19 pandemic. Long wait times, crowded waiting rooms, and frustrated patients can create volatile conditions.

Clinicians also experience moral injury. “Clinicians feel helpless, unsupported, and unable to provide the care they know patients need—not because they don’t care, but because the system won’t allow it,” Dr. Kelen said.

Boarding Through a Federal Policy Lens

Although hospital operations play a major role in boarding, federal policy also influences how hospitals respond to capacity pressures.

Dr. Michael

Sean Michael, MD, MBA, regional chief medical officer for the Centers for Medicare & Medicaid Services (CMS), said the agency views ED boarding as a system-level challenge rather than an emergency department issue.

“Crowding and boarding are fundamentally a demand-capacity mismatch across the entire health care delivery system,” Dr. Michael said.

From CMS’s perspective, boarding reflects patient flow dysfunction across the system—not failures inside a single department. “We sometimes say the term ‘ED boarding’ is a misnomer,” he said. “It describes where the patient is waiting, but the causes and solutions extend far beyond the emergency department.”

CMS approaches the issue through several policy levers, including quality measurement, regulatory oversight, payment models, and stakeholder engagement. One major initiative is the Emergency Care Access and Timeliness (ECAT) measure.

Beginning in 2027, hospitals will voluntarily report data on several indicators of emergency care access, including:

• Waiting more than 60 minutes for a treatment space
• Leaving the ED without evaluation
• Boarding more than four hours after the admission decision
• Emergency department length of stay exceeding eight hours

Mandatory reporting begins in 2028, with payment impacts expected by 2030.

“These measures are designed to capture failures in emergency care access,” Dr. Michael said. “From CMS’s perspective, that’s a hospital system issue—not just an ED metric.”

Why Incentives Matter

Although measurement is important, many experts believe financial incentives will ultimately determine whether hospitals make sustained changes.

Dr. Abir

According to Mahshid Abir, MD, MSc, a RAND researcher who helped lead the analysis, interviews conducted for the study revealed strong consensus among emergency physicians and policy experts.

“The majority of emergency physicians and emergency care policy experts interviewed believe that the most effective solution to ED boarding is tying it to payment,” Dr. Abir said.

Without financial incentives or penalties tied to boarding performance, health systems may struggle to prioritize long-term operational changes. Experts interviewed for the RAND study also emphasized the need for standardized national metrics.

“Federally mandated metrics are needed to track ED boarding at hospitals and measure the effectiveness of implemented solutions,” Dr. Abir said.

Such transparency could help policymakers, hospital leaders, and clinicians better understand how boarding varies across hospitals and whether new strategies are working.

Structural Bottlenecks Beyond the Hospital

Even when hospitals try to improve patient flow, broader system constraints often interfere.

Patients who are medically ready for discharge may remain hospitalized because appropriate post-acute placements are unavailable. Skilled nursing facilities, rehabilitation centers, and behavioral health beds remain limited in many parts of the country.

Insurance authorization requirements and administrative processes can also delay transfers. “These outflow bottlenecks create major challenges,” Dr. Michael said. “Patients who are medically ready for discharge can remain in hospital beds for days.”

When inpatient beds are occupied, patients admitted through the emergency department cannot be moved to an upstairs bed. The result is boarding.

The RAND report also highlights national trends contributing to the problem, including declining inpatient bed capacity relative to demand and geographic mismatches between hospital resources and patient needs.

Where Solutions Must Start

If the emergency department is not the cause of boarding, where should solutions begin? Dr. Kelen’s answer is direct. “The emergency department doesn’t cause boarding,” he said. “Boarding is a hospital problem.”

Addressing it requires engagement from hospital leadership, particularly the executive suite. “When hospital leadership—especially boards of trustees—tie executive compensation to boarding metrics, change happens fast,” Dr. Kelen said.

At Johns Hopkins, he noted, leadership tied executive compensation to boarding metrics. “Within weeks,” he said, “boarding was dramatically reduced.” Accountability, he argues, is critical. “When everyone has skin in the game, the system responds.”

Operational changes inside the emergency department, such as triage redesign or staffing adjustments, rarely resolve boarding on their own. Hospital-level strategies, such as smoothing surgical schedules across the week and improving discharge timing, have shown far greater impact.

A System Warning Signal

For frontline emergency physicians, boarding often feels inevitable. But experts say understanding the root causes of boarding is essential to addressing it.

Emergency physicians cannot solve the problem alone. Meaningful progress will require collaboration among hospital leaders, policymakers, payers, and clinicians.

For now, emergency departments remain the pressure valve of the U.S. health care system, absorbing the consequences of structural capacity constraints. But as policymakers increasingly recognize the patient-safety implications of boarding, experts say momentum for reform may finally be building.

Boarding is not an inevitable feature of emergency care. As Dr. Michael put it: “Boarding is not an immutable force of nature. It’s the result of system design, and systems can be redesigned.”

Leona Scott is a freelance writer based in Dallas.