“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.