WASHINGTON, D.C. —Extreme delays associated with boarding in the emergency department have become a national public health crisis. A study in the October issue of Annals of Emergency Medicine is the first of its kind to detail the daily costs of boarding for a hospital.

“Our analysis found that caring for patients who are boarding in the emergency department nearly doubled the daily cost of care for the hospital,” said Maureen M. Canellas, MD, MBA, FACEP, assistant professor of emergency medicine at the University of Massachusetts T.H. Chan School of Medicine, associate chief medical officer at the University of Massachusetts Medical Center, and lead study author. “Boarding is a systemic problem that requires collaborative solutions. This cost data should give hospital leaders a new perspective when addressing the boarding crisis.”

Boarding is hospital overload that occurs when already admitted patients are stuck in a holding pattern in the emergency department while waiting for an inpatient bed or transfer. These dangerous delays can last not just for hours, but for days, weeks, or longer.

• The study found that total daily cost per patient was $1,856 for those boarding, which is nearly double the $993 for those receiving inpatient care.
• The daily cost of boarding intensive care patients in the emergency department was $2,267 versus $2,165 for those being treated in the intensive care unit.

The authors examined the cost of care for 25 patients who suffered a stroke and then boarded in the emergency department for a combined 563 hours at a large urban academic comprehensive stroke center hospital. The study employed time-driven activity-based costing to quantify the care cycle by calculating daily resource use, salary data, and operating costs. This research was supported by the American College of Emergency Physicians (ACEP) Emergency Medicine Foundation and Emergency Medicine Policy Institute’s Health Policy Research Scholar Award.

Boarding is more costly than inpatient care and the overall costs of boarding are likely higher than reported, the authors noted. The study did not factor in other costs associated with prolonged hospital stays, including occupied beds unavailable for evaluation and treatment of new patients, staff inefficiencies, or the potential for malpractice lawsuits.

While this analysis focused on hospital costs, the dangers for patients are well established. Nearly 70 studies show that boarding is associated with elevated health and safety risks, prolonged delays in treatment, and increased likelihood of death. These dangerous bottlenecks are also associated with ambulance diversion, preventable medical errors, violent episodes, and care team burnout.  

ACEP efforts to address the root causes of boarding include alerting the White House, sounding the alarm through hundreds of troubling stories directly from the frontlines and tying boarding-related attestations to hospital performance measures, among other initiatives. Most recently, emergency physician-led advocacy culminated in an October 2024 stakeholder summit convened by the Agency for Healthcare Research and Quality.

“Despite research-proven risks for patients and severe strain on care teams and resources, the adoption of solutions to boarding nationwide has been inconsistent,” said Martin Reznek, MD, MBA, FACEP, professor of emergency medicine and vice chair of clinical operations and education at the University of Massachusetts T.H. Chan School of Medicine and UMass Memorial Health. “Hopefully, emergency physicians and others can use this new information related to boarding to accelerate conversations with policymakers and health care administrators, so that we can work together to protect patients and eliminate the boarding crisis.”