Emergency Department Boarding Practices in the United States

Purpose. This study describes: (1) the practice of emergency department (ED) boarding of medical and mental health patients in the U.S.; and (2) how patient, hospital and community characteristics relate to ED boarding.Background. ED crowding has been associated with a multitude of negative outcomes. The practice of boarding admitted patients in the ED is a significant factor associated with ED crowding. However, no quantitative analysis has been published that characterizes the extent of these boarding practices. Furthermore, few studies have focused on the population of mental health patients boarding in EDs.Methods. This study uses data from the 2008 National Hospital Ambulatory Medical Care Survey, a national probability sample of visits to U.S. EDs, to determine the proportion of EDs that board medical and mental health patients, the proportion of patients that are boarded, boarding times for these patients, and the characteristics of patients, hospitals, and community that are associated with boarding. Results. Bivariate analyses confirmed that boarding was practiced by a majority of EDs in the U.S. in 2008 (57.8%). The proportion of ED visits resulting in boarding was significantly higher for the mental health population (21.5%) than for other visitors (10.3%), and was especially high for the population of homeless mental health patients (43.4%). Mean patient boarding time was also significantly higher for the mental health population (292.7 minutes) compared to other visitors (205.0 minutes). One out of every eight hours of visit time spent in U.S. EDs in 2008 was consumed by boarding. Multilevel regression analyses demonstrated associations between longer boarding times and all mental health patients (1.4 additional hours, p<0.001), and especially homeless mental health patients (3.8 additional hours, p=0.001). Discussion. This is the first study known to describe U.S. ED boarding practices on a national level. Several important findings emerged from this study: 1) ED boarding is a nationwide problem; 2) mental health related visits are consistently associated with both a higher proportion of boarding and longer boarding times; and 3) the U.S. is in need of both increased facilities and services, and improved legislation and policies geared toward the mental health population