Patients admitted through the ER are getting measurably sicker while they board in ERs waiting for a hospital bed, according to a new study published in Annals of Emergency Medicine that delivers a stark warning about one of the most persistent failures in American hospitals.

These findings should alarm hospital leaders, policymakers and frankly anyone who may someday need emergency care.

Here’s the issue. Across America, thousands of patients every day are told they need to be admitted, but no inpatient bed is available. So they wait. Sometimes for hours; sometimes much longer. Patients wait on stretchers in hallways, behind curtains, in noisy, crowded spaces designed for short-term evaluation, not ongoing hospital care.

The dysfunction of ER boarding has become a normal part of U.S. hospital operations.

The study, led by researchers at Johns Hopkins University, is the largest analysis to date of clinical deterioration among boarded patients. Using more than six years of data from 2018 to 2024 across a five-hospital academic health system, the authors examined 173,168 patients admitted to general medicine beds.

Their question was simple: how often do patients worsen while boarding in the ED, and does longer boarding time matter? The answer: a resounding yes.

Among the patients studied, about 3.6%, experienced early clinical deterioration, defined as escalation from a standard inpatient bed to an intermediate care unit or ICU within 48 hours of the admission order.

Deterioration means that a patient’s illness worsened, and significantly so. For example, it can mean vasopressors were used for dangerously low blood pressure, a breathing tube was placed for mechanical ventilation or a patient needed much more intensive monitoring and treatment.

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Most striking, 45% of these deterioration events happened while patients were still physically in the ER before they ever reached an inpatient room.

The relationship with boarding time was concerning. Each additional hour of boarding was associated with a 0.8% increase in the risk of early deterioration. For patients who deteriorated while still in the ER, the increase was 2.4% per hour. Patients who boarded for 12 to 16 hours were more than twice as likely to deteriorate as those who boarded for less than four hours.

The consequences proved deadly. Patients who experienced early deterioration had a 28-day mortality rate of 13%, compared with 4% for those who did not. Among those who ultimately required ICU-level care, mortality rose to 18%.

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To be clear, this study does not prove that boarding itself directly causes every bad outcome. Observational studies can’t do that. Sicker patients may be more likely to board longer for reasons the data cannot fully capture.

But the message is hard to ignore: prolonged ER boarding is linked to measurable harm. The longer patients wait, the risks worsen by a large margin.

ER boarding not only matters for the boarded patient, but for everyone else in the waiting room. Boarding is one of the main reasons ERs become gridlocked. Once admitted patients pile up in ER beds, doctors and nurses have less room and less time to evaluate new arrivals.

Wait times rise. Treatment is delayed. More patients leave without being seen. Clinicians are stretched thinner. The entire front end of the hospital starts to fail.

What Hospitals Can Do To Address ER Boarding

Hospitals have options, all of which are challenging and require both leadership and resources to implement.

One underused strategy is what’s called surgical schedule smoothing. Many health systems cluster high-volume elective procedures early in the week, which predictably fills inpatient beds and leaves little room for ER admissions. Spreading those cases more evenly throughout the week or even weekend can reduce peak bed occupancy and relieve pressure on the ED.

Hospitals can also use full-capacity protocols, which move admitted patients out of the ER to distribute them across inpatient units when crowding reaches a certain threshold. A related strategy is what are called “pull systems,” where inpatient teams actively take ownership of admitted patients rather than allowing them to wait in the ER.

Accelerating discharges is another lever. Earlier discharge planning, morning discharges and discharge lounges free up beds sooner, reducing the backup in the ER. And in safety-net hospitals, where this study found especially high boarding times and deterioration rates, targeted investments in nursing may be one of the highest-yield interventions available.

Policy Solutions To Address ER Boarding

A deeper problem underlying ER boarding is how it impacts the financial reality of hospital budgets, which already run on razor-thin margins. Hospitals often depend on scheduled admissions and elective procedures as major revenue drivers. That creates a perverse incentive, because it is those very patients who are occupying beds while patients are waiting for admission in ER hallways.

So even when boarding is dangerous and operationally destructive, hospital leaders may still be reluctant to disrupt the profitable parts of the system to fix it.

That is why policy change has to be part of the solution. The American College of Emergency Physicians has continuously pushed for stronger accountability, including contingency response plans when boarding exceeds defined thresholds and clearer benchmarks, such as a four-hour standard after the decision to admit.

There is a new national measure of emergency care access and timeliness called the Equity of Emergency Care Capacity and Quality, developed in partnership between CMS and Yale University, that includes boarding time as a component, along with several other measures of visit timing.

States have started to take the lead on this, too. Connecticut, for instance, now posts boarding times. Other groups, including the Leapfrog Group, have also piloted measures of ER boarding.

ACEP has also supported a new proposed legislation called the Addressing Boarding and Crowding in the Emergency Department Act. The law proposes a real-time hospital bed tracking system to monitor boarding times. It also authorizes the CMS Innovation Center to pilot specialized care models for high-risk populations — specifically geriatric and psychiatric patients — who often suffer the longest wait times. Finally, to ensure long-term accountability, it mandates a Government Accountability Office study on hospital capacity best practices and expands grants to track EMS offload times to keep ambulances on the road.

On the accreditation side, the Joint Commission has long required hospitals to address patient flow. This has helped keep attention on patients who board in the ER for more than four hours after the decision to admit. Yet its standards around boarding are unevenly enforced when hospitals fail to improve.

Importantly, none of these steps alone directly solve America’s boarding problem. But what they do is to move hospitals to take more action on the issue.

Ultimately, ER boarding has historically been treated as a problem that’s too hard or too expensive to fix. The new study makes that position increasingly harder to defend.

When patients sick enough to be admitted to the hospital are deteriorating behind curtains and in hallway beds while they wait for space upstairs, it is not just a flow problem. It is a fixable safety failure that deserves focus and attention.

© Forbes