Patient Boarding in the ED Soars by A Third at MGH, Harms Experience

Massachusetts General Hospital (MGH) is boarding patients in the emergency department nearly a third more often than it has in the past, marking a serious capacity problem that’s impacting patient access to care and the patient experience.

Patient “boarding” is the practice of keeping a patient in the emergency department after they have been admitted into the hospital because there are not enough inpatient beds. Boarding can cause serious ED overcrowding problems, which can have their own downstream consequences, according to the American College of Emergency Physicians.

Ambulance refusals, prolonged ED wait times, and increased patient harm, such as being left in department corridors, are all results of patient boarding. In some cases, patient boarding and ED overcrowding can impact the hospital’s ability to respond to community emergencies or disasters, according to ACEP.

MGH is outlining the extent of the patient boarding problem at its own facility in this latest analysis, showing that between October 2022 and September 2023, patients were boarded in the ED for a total of 381,228 hours. This is a 32 percent increase from the previous 12-month period, MGH said.

This increased patient boarding in the ED has caused MGH to escalate its emergency department status from “Normal Operations” to “Code Help” or “Capacity Disaster,” which the hospital says indicates critical levels of ED overcrowding. In “Code Help,” inpatient beds and monitored stretchers are all full; in “Capacity Disaster,” the ED is full, all hallway stretchers are in use, and there are more than 45 inpatients boarded in the ED.

For the past 16 months, the MGH emergency department has operated “nearly every day” in those two above-mentioned statuses, the hospital said.

ED overcrowding has clear impacts on hospital operations, but patient boarding is also a patient experience issue. In September 2023 alone, patients boarded at the MGH emergency department were left boarded for a median of 14.1 hours; 26 percent of admitted patients boarded in the ED for more than 24 hours, MGH said.

On January 11, 2024, MGH had 103 patients boarded in the emergency department, which the hospital said was one of the most crowded days it’s had in nearly 200 years of serving Boston and surrounding towns.

Being boarded is not a good patient experience, MGH acknowledged. Patients being boarded are often left waiting in stretchers or chairs in the hallways of the ED or in other temporary spaces. There is little comfort nor patient privacy, and none of that is to mention the patient safety issues that often arise with patient boarding.

According to MGH President and former department chair of Emergency Medicine David F.M. Brown, MD, the influx of patient boarding in the ED is largely the result of the COVID-19 pandemic, which stretched MGH and its peer hospitals to their limits.

“While hospital overcrowding has significantly affected patient care for many years, COVID-19 and the post-pandemic demand for care has escalated this challenge into a full-blown crisis – for patients seeking necessary emergency care, as well as for staff who are required to work under these increasingly stressful conditions,” Brown said in a statement.

“This crisis is most acutely felt in our ED, where patients wait hours for an inpatient bed. Put simply, every day between 50 and 80 patients spend the first night of their hospitalization in the ED, which is not an appropriate or therapeutic environment for anyone and contributes significantly to clinician burnout and frustration.”

This assessment came on the heels of a January 9 memo from the Massachusetts Department of Public Health (DPH) urging expedited discharge planning as soon as it is safe for patients.

As part of its plan to address the boarding problem, MGH said it has sought to net an increase of 94 licensed inpatient beds on its existing campus once the construction of the Philip and Susan Ragon Building is complete. By increasing the number of inpatient beds, MGH indicated it will be able to build greater capacity in the ED.

“We will always provide care to every person who crosses our threshold – a responsibility we take extremely seriously,” Brown explained.

“We have improved inpatient throughput and efficiency and developed innovative care models across our health system and yet we still face overwhelming and increasing ED crowding with no end in sight,” Brown added. “That is why adding more beds to MGH will greatly help alleviate this capacity crisis, enhance access for patients and substantially improve the overall working conditions for our clinicians and staff.”

MGH will also further bolster the hospital’s Discharge Lounge, where patients can wait during discharge prior to leaving the hospital. The typical patient spends around an hour in the Lounge before leaving the facility, which frees up beds earlier for those admitted through the ED. The Lounge has also proven effective in addressing transportation as a social determinant of health because it provides a Care Van service for those in need.

By leveraging hospital-at-home services, leveraging transitions of care, and collaborating with the neighboring Cambridge Health Alliance for low-acuity ED overflow, MGH said it also hopes to ameliorate its overcrowding and boarding woes.

Patient boarding isn’t just an MGH problem. A September 2022 analysis in JAMA Network Open showed that patient boarding was happening more often post-pandemic. A separate March 2022 Health Affairs blog post indicated that certain financial incentives may reduce the practice of patient boarding.

But for hospitals like MGH facing limitations with inpatient beds, it may require further examination to identify solutions to the patient boarding problem.