High Levels of Concern About ED Boarding Crisis

Emergency department (ED) boarding in the United States has escalated to crisis levels, sparking significant concerns among adults, according to a poll conducted on behalf of the American College of Emergency Physicians in September 2023. This issue not only affects patient care but also has far-reaching consequences for the efficiency of emergency medical services (EMS).

The survey interviewed 2164 adults and showed that an overwhelming majority (80%) expressed serious concerns about the boarding crisis. Moreover, 43% of respondents either delayed seeking medical care at an ED or avoided it altogether if they anticipated prolonged wait times before being admitted to the hospital or transferred to another facility.

Nearly half of adults (44%) experienced long wait times following initial care in an ED, and 16% of these adults reported 13 or more hours of waiting after receiving initial care.

“The boarding crisis is a predictable result of an acute care hospital system with insufficient capacity — we lack enough space and staff in our acute care hospitals, as we have not created the bed capacity needed for an aging and higher acuity patient population, and staffing shortages for inpatient beds have resulted in a longer hospital length of stay that we observe as boarding patients in the ED,” Arjun Venkatesh, MD, the chief of emergency services at Yale New Haven Hospital, told the Medscape Medical News, commenting on the factors contributing to this crisis.

One concerning side effect of boarding in EDs is the delayed response of ambulance services. When a hospital is unprepared to receive patients arriving in an ambulance, ambulance crews often wait with the patients for extended periods until the hospital can admit them. This situation can have critical implications, as parked ambulances are unable to respond to other emergencies in the community.

Adults who have endured long wait times in EDs voiced concerns about the negative impact such delays can have on their medical care. The experiences of patients and their families have underscored the urgency of addressing the boarding crisis.

“There are no low-hanging fruit solutions or simple communication strategies to alleviate these concerns,” said Venkatesh, adding that “the only way to change that perception is to change the care by addressing the lack of inpatient capacity and community care capacity to avoid back-up in the ED.”

The poll revealed that 93% of adults across different demographic groups considered EMS, including paramedics, essential. Older adults were more likely to emphasize the significance of these services than younger adults.

“We all need a place for people to go when there is an emergency, whether it be trauma, a heart attack, a stroke, or similar conditions,” said Scott Weiner, MD, an associate professor of emergency medicine at Harvard Medical School and attending emergency physician at Brigham and Women’s Hospital.

“However, the modern ED is much more than that. It has become the center for coordination of care across the health system where diagnostic tests can be completed promptly, where follow-up care is arranged, and where behavioral health emergencies come,” he added.

A vast majority, 89%, believed that additional or supplemental government funding should be directed toward these essential services, highlighting the public’s concern for the accessibility of EMS.

Weiner stressed the need for a complete realignment of the payment system, “It’s unfair that public insurance like Medicaid reimburses sometimes less than a quarter of the rate that commercial insurance pays for the exact same service. This exacerbates and perpetuates disparities in health.” According to him, the solution may involve transitioning to a single-payer model, but it could face significant challenges owing to people’s apprehensions about changes in their healthcare and negative perceptions of “socialized” medicine in other countries. Furthermore, the poll found that the largest share of adults (42%) believed that hospitals should take the lead in improving boarding and shortening ED wait times. These findings indicated the need for hospitals to reevaluate their processes and capabilities to reduce boarding and enhance the overall patient experience in EDs.

“The top three entities that can fix the boarding crisis are hospitals, Congress, and insurance companies,” noted Wiener. “However, until there is parity at all levels, hospitals will continue to accept lucrative elective admissions but allow ED patients to linger without a bed,” he added.

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