Patient and staff safety implications of emergency department boarding: a systematic review

Emergency departments (EDs) are a vital part of the US healthcare system, yet they are increasingly overwhelmed by the practice of boarding, which involves holding admitted patients in the ED after the decision for hospital admission has been made. Despite extensive evidence, the issue has only worsened. Evidence-based policymaking requires analysis of contemporary studies differentiating boarding from broader crowding consequences.

Leveraging US-based literature from 2014 to 2024, this review synthesizes the health and safety effects of boarding on patients and staff. Twenty-one studies were included: 17 on patient outcomes and 4 on staff impacts.

Prolonged boarding times were associated with severe consequences, including worsened mortality, morbidity, length of stay, medication errors, and treatment delays. High-risk populations (eg, pediatric, psychiatric, and older) suffered greater harm. For clinical staff, boarding added workload, hindered resident education, and worsened burnout.

This review extends previous studies' findings and supports the proposition that boarding (distinguished from crowding more generally) is not only an operational inconvenience but also a systemic safety hazard with implications for healthcare and policy leaders as they prioritize strategies to improve patient safety. The largest opportunity for further research is in rigorous, prospective, multi-center studies with standardized definitions and outcome measures.