Staffing Trends Amid Boarding Challenges: A Five-Year Analysis (2019-2023)

To examine trends in clinician staffing in the context of rising Emergency Department (ED) boarding we describe five-year national trends (2019-2023) in boarding hours, attending physician and PA/NP coverage, and hospitalist and nursing support across a multicenter cohort of U.S. EDs.

We conducted a retrospective cohort study using data from the Association of Academic Chairs of Emergency Medicine (AACEM) and Academy of Administrators in Academic Emergency Medicine (AAAEM) annual benchmarking survey for academic years 2019 through 2023. The analysis included primary academic, academic affiliate, and community affiliate EDs. Boarding hours, attending physician and PA/NP hours, nursing support, and hospitalist care for patients boarding were evaluated over time. Outcomes were stratified by hospital classification.

63 EDs were included in our analysis. Median boarding hours/day increased 61.1% from 206.36 (IQR 89.87, 373.11) to 332.47 (137.43, 548.09) (p = 0.01), while median attending hours remained stable over this time frame from 72.00 (53.90, 91.50) to 72.00 (56.00, 88.00) (p = 0.56). The boarding-to-attending hour ratio increased 55.6% overall from 2.97 (1.33, 4.04) to 4.62 (2.15, 7.42) (p = 0.002). Hospitals providing nursing support for boarders increased 53.6% (95% CI 3.20%, 134.40%) which was statistically significant, whereas hospitalist management of boarding patients increased 28.7% (95% CI 2.60%, 68.10%) which was not statistically significant.

ED boarding hours increased substantially over the study period without a proportionate rise in attending staffing, resulting in a marked increase in boarding burden per physician hour. While some hospitals provided funding for increased nursing and hospital coverage to care for boarding patients, these measures have not kept pace with rising boarding demands. These findings highlight a growing mismatch between workload and staffing, underscoring the need for updated staffing models and system-level strategies to address the operational and clinical challenges of ED boarding.