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Waiting for a hospital bed: Disparities in emergency department boarding
Rose M Olson1,2, Nathaniel Fessehaie1,2, Trishathi Malagar Nandakumar1
1Department of Medicine, Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA.
Background:
Rising emergency department (ED) boarding times have become a public health crisis. It is unclear whether certain racial and ethnic groups are disproportionately affected.
Objective:
To identify racial and ethnic inequities in ED boarding time and explore which factors may contribute to prolonged boarding times.
Design, Setting, And Participants:
Retrospective cohort study of 38,766 adults (≥18 years) admitted to internal medicine services from EDs at two Boston hospitals (March 2018-February 2024).
Measurements:
Race and ethnicity categorized as non-Hispanic White (White), non-Hispanic Black (Black), Hispanic, and non-Hispanic "Other" (including Asian, American Indian/Alaska Native, Native Hawaiian/Pacific Islander, or unspecified).
Primary Outcome:
prolonged ED boarding (≥4 h from admission order to inpatient transfer). Multivariable logistic regression assessed associations; additional analyses evaluated health insurance as a mediator.
Results:
Among 38,766 patients (53.1% female), 59.9% were White, 20.3% Black, 14.4% Hispanic, and 5.4% "Other" race and ethnicity. Prolonged ED boarding occurred in 32.1%. In adjusted models, Black patients had 9% higher odds (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.03-1.15; p = .004) and "Other" racial and ethnic patients had 16% higher odds (OR, 1.16; 95% CI, 1.05-1.27; p = .003) compared to White patients of prolonged ED boarding; no significant difference was observed for Hispanic patients (OR, 0.98; 95% CI, 0.92-1.04; p = .51). Adjusting for insurance attenuated racial disparities in ED boarding. Medicaid insurance was consistently associated with increased odds of prolonged boarding across racial and ethnic groups, particularly among Hispanic (OR, 1.86; 95% CI, 1.63-2.12; p ≤ .001) and Black (OR, 1.78; 95% CI, 1.59-1.99; p < .001) patients. Medicare was associated with lower odds of prolonged boarding across all groups.
Limitations:
Two-site study.
Conclusions:
Black and other marginalized racial and ethnic patients were more likely to experience prolonged ED boarding, and differential health insurance access may contribute to this inequity. As boarding rises nationally, targeted interventions are needed to reduce disparities.
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