Written by Joshua Dodge and Ketan Patel
Spoon Feed
Among adult ED boarders, longer boarding duration plus each extra hour a patient waits for an inpatient bed portends higher risk and early clinical deterioration, with patients who deteriorate having substantially higher 28-day mortality.
Boarder crisis
Prior work linked boarding and crowding to mortality and delays in care, but evidence has been sparse and mixed on how often boarders clinically decompensate and whether boarding time itself independently drives early escalation of care.
This 5-hospital retrospective study (2018–2024) examined early clinical deterioration among 173,168 adult medicine ED patients boarding 4–48 hours. Early clinical deterioration, defined as escalation to intermediate care or ICU within 48 hours of admission orders, occurred in 6,299 (3.6%), with 45% occurring in the ED. Boarding was independently associated with deterioration overall (aOR 1.17; 95%CI 1.10–1.24), with a stronger association for deterioration occurring in the ED (aOR 1.58; 95%CI 1.46–1.71). Patients with early deterioration had higher 28-day mortality than those without deterioration (13.0% vs 3.9%; OR 3.66; 95%CI 3.38–3.96).
This retrospective analysis in a single health system relies on non-standardized escalation criteria, cannot establish causality, may miss deterioration without level-of-care change, and may not generalize to sites with different boarding burdens, staffing, or ICU admission practices.
How does this change my practice?
This study reinforces that ED boarders are not “stable admits” just because admission orders exist. It supports the practice of structured reassessment of ED boarding patients, especially during shift changes, and prioritizing monitored placement when possible to frequently assess deterioration. These findings also strengthen the argument for early disposition, hospital-wide throughput initiatives, expansion of healthcare infrastructure, and appropriate staffing.
Source
Early Clinical Deterioration Among Emergency Department Boarders: A Retrospective Analysis. Ann Emerg Med. 2026 Mar 19:S0196-0644(26)00071-5. doi: 10.1016/j.annemergmed.2026.01.023. Epub ahead of print. PMID: 41860510.
