The Emergency Department and Psychiatric Boarding: A Model for the Future: 2026 Update.

The median emergency department (ED) boarding time for admitted patients has been a nationally reportable core measure that now also affects ED accreditation and reimbursement. However, no direct national probability samples of ED boarding data have been available to guide this policy until now. The authors studied new National Hospital Ambulatory Medical Care Survey (NHAMCS) survey items to establish baseline values, to generate hypotheses for future research, and to help improve survey quality in the future. This was a cross-sectional, multistage, stratified annual analysis of EDs and ED visits from the National Hospital Ambulatory Medical Care Survey public use files from 2007 to 2010, a total of 139,502 visit records. These data represent the only national measure of ED boarding. The main outcome of interest was boarding duration for individual patient visits. Data analyses accounted for complex sampling design. The national median boarding time was 79 minutes, with an interquartile range of 36 to 145 minutes. The prevalence of boarding for more than 2 hours among admitted patients was 32% (95% confidence interval [CI] = 30% to 35%). Average ED volume, occupancy, acuity, and hospital admission rates increased abruptly from the second to the third quartile of median boarding duration. The half of hospitals with the longest median boarding times accounted for 73% of ED visits and 79% of ED hospitalizations nationally. Thirty-nine percent of EDs (95% CI = 32% to 46%) reported never holding patients for more than 2 hours, but visit-level analysis at these EDs found that 21% of admissions did in fact stay in the ED over 2 hours. Only 19% of EDs (95% CI = 16% to 22%) used a strategy of moving admitted patients to alternative sites in the hospital during crowded times. In this national survey, ED boarding of admitted patients disproportionately affects hospitals with higher ED volumes, which also see sicker patients who wait longer to be seen, but not hospitals with higher proportions of Medicaid or uninsured visits. This finding implies that, unlike other quality measures, there is a negative volume-outcome relationship for timely hospitalization from the ED.

The COVID-19 pandemic forced unprecedented challenges for emergency department operations during the spring of 2020. Before the COVID-19 pandemic, psychiatric boarding in emergency departments required a substantial amount of staffing and administrative resources. This case study describes one state's efforts to rapidly decrease psychiatric boarding by 93% in 2 weeks with a multipronged approach, and simultaneously minimal effects observed on outcome measures of psychiatric hospital readmissions and suicide rates. Lessons learned are discussed regarding workflow adaptations and leadership implications.

Psychiatric boarding in Emergency Departments (ED) is a global challenge which results in long ED length of stays (LOS) with significant consequences on patient care and staff safety. This study investigated the impact of an initiative to reduce psychiatric boarding on LOS and readmission rate, as well as explored the relationship between boarding times and LOS. This study was conducted at Mitchells Plain Hospital, a large district-level hospital in Cape Town. This cross-sectional study collected data for 24 months, which included a 9-month period prior to the initiative and 16 months thereafter. Data were collected retrospectively from official electronic patient registries. The initiative comprised of inpatient hallway boarding as a full-capacity protocol with the accompanying capacitation of psychiatric wards to accommodate the additional burden. The initiative was associated with a decrease of 95% (p < 0.001) in boarding time, 13% (p < 0.001) in ward LOS and 25% (p < 0.001) in hospital LOS. Ward LOS were found to be independent of ED boarding times. The readmission rate increased from 12% to 18% post intervention. The initiative resulted in a sustainable improvement in boarding times and LOSs. The observational nature of this study precludes concrete conclusions and further investigations into psychiatric inpatient hallway boarding are recommended. Inpatient hallway boarding could be a feasible option to reduce the risk. Psychiatric boarding times in the ED are independent of ward LOS, rendering it devoid from any value from a lean and economic perspective.

The cost of waiting: Association of ED boarding with hospitalization costs.

Although emergency department visits for people in psychiatric crisis have been steadily increasing in the United States, the lack of affordable, comprehensive psychiatric treatment is largely to blame for psychiatric boarding in emergency departments, according to an Evidence Brief released last week by the Treatment Advocacy Center (TAC). People with serious mental illness are disproportionately affected by psychiatric boarding, the brief stated.

Introduction: Emergency department (ED) boarding is associated with worse outcomes for critically ill patients. There have been mixed findings in other patient populations. The primary objective of this study was to examine predictors of prolonged ED boarding among cancer patients receiving chemotherapy who required hospital admission from the ED. Secondary objectives were to examine the association between prolonged ED boarding and in-hospital mortality, 30-day mortality, and hospital length of stay (LOS). Methods: Using administrative databases from Ontario, we identified adult (≥ 18 years) cancer patients who received chemotherapy within 30 days prior to a hospital admission from the ED between 2013 to 2017. ED boarding time was calculated as the time from the decision to admit the patient to when the patient physically left the ED. Prolonged ED boarding was defined as ≥ 8 hours. Multivariable logistic regression was used to examine predictors of prolonged ED boarding and to determine if prolonged boarding was associated with mortality. Multivariable quantile regression was used to determine the association between prolonged boarding and hospital LOS. Results: 45,879 patients were included in the study. Median (interquartile range (IQR)) ED LOS of stay was 11.8 (7.0, 21.7) hours and median (IQR) ED boarding time was 4.2 (1.6, 14.2) hours. 17,053 (37.2%) patients had prolonged ED boarding. Severe ED crowding was the strongest predictor of prolonged ED boarding (odds ratio: 17.7, 95% CI: 15.0 to 20.9). Prolonged ED boarding was not associated with in-hospital mortality or 30-day mortality. Median hospital LOS was over 9 hours (p &lt;0.0001) longer among patients with the longest ED boarding times. Conclusion: Severe ED crowding was associated with a significant increase in the odds of prolonged ED boarding. While our study demonstrated that prolonged boarding was not associated with increased mortality, further work is required to understand if ED boarding is associated with other adverse outcomes in this immunocompromised population.

Emergency department (ED) boarders, namely patients who have been admitted under an in-patient service but remain on a trolley in the ED, have long been a problem in the Irish healthcare system. We conducted a retrospective analysis of all ED boarders in Cork University Hospital (CUH) for a 6-month period from January to July 2011. Data were obtained from the Hospital In-Patient Enquiry Office (HIPE). The income generated by the hospital for a subset of these patients (January and February attendances) was obtained from the Finance Office in the hospital, based on diagnoses as recorded on the HIPE system. A convenience sample of two-thirds of the 39 acute hospitals nationally was surveyed to ascertain whether ED boarders were coded by individual HIPE offices as hospital in-patients or as ED attendees. A total of 806 patients were admitted to an in-patient service from January to July 2011 in CUH and subsequently discharged, having completed their entire stay in the ED. The income generated by a sub-sample of 228 patients (January and February ED boarders) was determined. The hospital was remunerated by <euro>685,111 for these patients, i.e. an average income of <euro>3,098 per patient. Only 8 hospitals of the 27 surveyed hospitals coded overnight ED Boarders as in-patients and were thus able to request income for these patients appropriately. Discrepancies in coding of ED boarders may result in significant revenue losses for certain hospitals.

The boarding of Psychiatric Emergency Department patients continues to be a crisis across our country. As healthcare leaders navigate the challenges of COVID -19 there is an amplified urgency for novel solutions to this complex problem. Congested waiting rooms and hallways, the unfortunate byproduct of boarding, result in emergency departments becoming a potential focal point for disease transmission. Given the financial losses that many health care institutions have incurred due to the pandemic, understanding the fiscal implications of any intervention is paramount.

Pearls About Swine: How Emergency Departments Are Coping With the Surge of H1N1

Emergency department (ED) boarding is a major threat to timely and safe care delivery. Addressing boarding requires an understanding of which patient populations are significantly impacted to formulate solutions. Our objective was to evaluate the median ED boarding time of mental health compared to non-mental health patients. We performed a database analysis using the National Ambulatory Care Reporting System data from 96 EDs from September 1, 2018, to September 30, 2023. International Classification of Diseases 10th Revision codes were used to define mental health and non-mental health subgroups for all patients admitted from the ED who were greater than 18years old. Boarding was defined as the elapsed time between the admission decision to when patients departed the ED. Descriptive statistics summarized ED visit characteristics and median (IQR) boarding time throughout three study periods. An interrupted time series analysis evaluated boarding trends to account for COVID-19 variation. During the study period, 887,494 patients were admitted from an ED with mental health (113,209; 13%) or non-mental health (774,285; 87%) diagnoses. The mental health subgroup was younger, with a median age of 40, and predominantly male (57.1%). The median (IQR) boarding time for mental health patients was 120% longer (282 min (79-1113)) compared to non-mental health (128 min (58-420)). When comparing the initial and final study periods, mental health patient boarding increased by 76% (199min), and non-mental health patient boarding increased by 24% (29min). This is the most extensive Canadian study comparing ED boarding for mental health and non-mental patients. The results demonstrate that mental health patients experience disproportionately longer ED boarding compared to other patient presentations, and the trend remains consistent over time. This emphasizes the need to address inequities in resourcing inpatient beds and adjust the current care model for mental health patients.

Boarding is associated with higher rates of medication delays and adverse events but fewer laboratory-related delays

IntroductionEmergency department (ED) boarding, the process of holding patients in the ED due to a lack of inpatient beds after the decision is made to admit, has profound consequences. Increased ED boarding times are associated with adverse patient outcomes, including increased mortality. While previous studies have demonstrated racial disparities with regard to ED boarding, current literature lacks insight into discrepancies that may exist among other demographic groups as it pertains to ED boarding. We sought to review ED boarding times differentiated by demographic characteristics.MethodsWe conducted a retrospective review of all ED admissions from an academic ED in the Southeast from April–September 2019. The primary outcome assessed was boarding time, defined as time from decision to admit to ED departure. Patient demographic data including race, gender, and age were collected and analyzed. We performed descriptive statistics and chi-square analyses.ResultsThe study population included 17,606 patients with a mean age of 56.3. Nearly half (49.8%) of the patients were female. Additionally, 43.8% of patients were Black and 48.6% White. For all admissions, there was no difference in mean boarding time among Black and White patients (5.2 ± 8.8 vs 5.2 ± 8.2 hours, P = 0.11). Among Emergency Severity Index (ESI) level I admissions, Black patients boarded longer than White patients (4.1 ± 0.3 vs 2.7 ± 0.3 hours, P = 0.009). Black patients also boarded significantly longer than White patients for psychiatric admissions (22.7 ± 23.7 vs 18.5 ± 19.4 hours, P <0.05). For all admissions, males boarded longer than females (5.5 ± 8.5 vs 4.9 ± 8.2 hours, P <.0001). Patients older than 75 boarded for less time (3.8 ± 6.2 hours) compared to younger groups (15–24: 6.4 ± 10.8 hours; 25–44: 6.6 ± 10.8; 45–64: 5.0 ± 7.6; and 64–75: 4.7 ± 6.7; all P <.05).ConclusionThis analysis demonstrated significant differences in ED boarding times between races among psychiatric and ESI I admissions, gender, and age. This data provides insight into differences in ED boarding times among demographic groups and provides a focal point for examining possible factors contributing to the observed differences.

Background: Emergency Department (ED) boarding—defined as the time patients remain in the ED after the admission decision—is a major determinant of ED crowding, patient harm, and system inefficiency. Prolonged ED stays are associated with delays in definitive management, higher complication rates, and increased mortality. The objective is to determine the incidence of extended ED boarding (≥48 hours). To compare adverse events between overstayed and timely-shifted patients. 3. To identify system-level causes contributing to prolonged boarding. Material and Methods: A prospective observational study was conducted over six weeks in the ED of a tertiary-care teaching hospital. Patients with admission decisions were enrolled through simple random sampling. Charlson Comorbidity Index (CCI) was used for stratification. Patients were grouped into ≤48 hours (timely transfers) and &gt;48 hours (extended boarders). Adverse events were compared using Chi-square/Fisher’s exact tests, and relative risks were computed. Data sources included medical records, admission files, and daily transfer logs. Results: Among 300 patients, 96 (32%) boarded &gt;48 hours. System-level contributors included limited bed capacity, delayed discharges, pending consultant decisions, diagnostic delays, communication gaps, delayed visibility of vacant beds, inappropriate specialty assignment, and preferential transfers. Across all CCI strata, overstayed patients experienced significantly more adverse events. Overstayed patients had higher risks of mortality (RR 3.19), ICU mortality (RR 3.54), hospital-acquired infections (RR 3.34), medication errors (RR 3.07), delayed treatment (RR 2.48), and prolonged LOS (RR 3.05). Even patients with CCI = 0 had an eight-fold higher risk of adverse events (RR 8.63). Conclusion: Extended ED boarding is common and strongly associated with preventable clinical harm, irrespective of comorbidity burden. Systemic inefficiencies—particularly delayed discharges and bed non-availability—were major contributors. Improving discharge processes, real-time bed visibility, diagnostic turnaround, and interdepartmental coordination may significantly reduce ED boarding and improve patient outcomes. Keywords: ED boarding; emergency crowding; Charlson Comorbidity Index; delayed transfer; inpatient flow; mortality; adverse events.

Increases in emergency department (ED) presentations for mental health conditions continue to challenge the national mental healthcare infrastructure, often resulting in ED boarding. However, limited prior studies capture the perspectives on mental healthcare of those experiencing prolonged boarding in the ED (≥ 24 hours stay) for mental health conditions. We aimed to assess patient perspectives on acute mental healthcare among individuals boarding in a general ED in a rural state. We performed semi-structured interviews of adults (≥18 years old) presenting with a primary mental health condition boarding in a general ED for at least 24 hours. An interview guide was developed a priori, and a trained study team performed the interviews. A thematic analysis was conducted by two independent coders. A coding tree was developed through an iterative process that included double-coding transcripts and monitoring of inter-rater reliability. Fifteen patients were interviewed to reach saturation. Ages ranged from 22 to 65. Analysis revealed several key themes including the environment of the ED, interactions with family members and staff, communication regarding the plan of care, patient perceptions of autonomy and respect, and mental healthcare services provided outside the ED. Our study revealed that adults encounter significant challenges to access timely acute mental healthcare in the ED in a rural state. Participant recommendations for improvement included increasing the availability of therapy while in the ED and providing a physical environment that is more welcoming. Community, hospital-based, and statewide quality improvement and public policy strategies should be considered to address the identified challenges.

277: The Association Between Length of Emergency Department Boarding and Mortality: A Multicenter Study