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.