Allen Dao is a biology major and a 2023-24 health care ethics intern with the Markkula Center for Applied Ethics at Santa Clara University. Views are his own.
In September 2023, nurses at UC San Diego Health Jacobs Medical Center in La Jolla protested outside the Emergency Department (ED), demanding that the medical center address overcrowding and boarding. Boarding, the practice of retaining patients in hallway gurneys or chairs instead of rooms, is an unsafe and unethical practice. One nurse shared how a code-blue patient received cardiopulmonary resuscitation (CPR) in the hallway as on-looking strangers walked by, highlighting eroding patient care conditions. These scenarios are not isolated but a symptom of a broader systemic issue.
It is standard practice for Emergency Room (ER) patients to be triaged, placed in hallway beds, and treated in the presence of passersby. It is also common to see boarded patients wait for 4 to 5 days in hallways before securing an inpatient room. However, these concerns are only the tip of the iceberg. Multiple problems arise from ED overcrowding: longer wait times, longer hospital stays, more medical errors, higher patient death rates, employee burnout, and more financial pressure on hospitals. Ultimately, the combination of these issues impacts patients and providers while causing strain on the entire hospital system.
I have seen this complex issue firsthand during my one-year tenure working in the ED at a medical center. Shift after shift, I saw how common overcrowding and patient boarding were in the ER. It was unsettling to watch patients yell for medical attention or groan in pain in the hallway while waiting to be treated. One nurse would commonly be responsible for six patients at a time, and physicians often spent less than ten minutes per patient at bedside. Because of this practice, patients were confined to the hallway and spent most of their visit alone. I could see these patients were uncomfortable as they were isolated yet left in the open without privacy. Over time, these encounters became the norm as there were too many patients to treat with limited staff and available rooms. Overcrowding is a crisis that manifests in the frontline of hospitals, overwhelming EDs across the nation.
How did this happen?
Overcrowding is the result of an imbalance between supply and demand characterized by an excessive number of patients waiting for consultation, diagnosis, treatment, transfer, or discharge. It is a well-defined issue but underappreciated. Evidence-based research suggests that there are three main causes of overcrowding: the incoming volume of patients (input), the time to process and treat patients (throughput), and the volume of patients leaving the ED (output).
In 2016, the volume of patients arriving and waiting to be seen in the ED rose more than 60% since 1997 to about 146 million, with nearly 46 visits per 100 persons of the civilian noninstitutionalized population of the United States. An increase in input has various explanations: more presentations requiring complex care, disparate access to primary care, inappropriate use of emergency services, viral outbreaks, and seasonal illnesses. EDs cannot control input factors; efforts are limited to mitigation. Due to this unpredictability, challenges lie in addressing input without compromising the quality and timeliness of patient care.
Once patients arrive at the ED, internal factors come into play, leading to inefficiency that prolongs the time from admission to discharge, hospitalization, or patient transfer. This period, known as throughput, encompasses the processing and treatment of patients. Staffing shortages, limited resources, workflow inefficiencies, and bed availability negatively impact throughput. In addition, delays in diagnostic tests, treatment administration, and specialist consultations all hinder the flow of patients.
Following evaluation and treatment by a provider, stabilized patients are ready to leave the ED via discharge or hospital admission. In overcrowded EDs, an exit block occurs as admitted patients have to stay and wait to progress onto the next steps of their care plan. A direct byproduct of stagnant output is boarding, which exclusively happens to patients awaiting an inpatient bed. Boarding has negative effects on mortality, patient satisfaction, and quality of care. Consequently, many problems that lead to overcrowding are interconnected and show the urgent need for systemic reform.
The urgency to address this problem has increased substantially, as the effects of the COVID-19 pandemic affected the entire overcrowding triad. Due to lockdown protocols, patients no longer received routine check-ups from their primary care physicians or managed their chronic illnesses, resulting in a surge of patients seeking emergency care. EDs responded to this by implementing strict infection control measures that required personal protective equipment for providers and established COVID-specific units, which was necessary but slowed down triage, diagnosis, and treatment. What hospitals could not prepare for was the sheer number of patients who developed severe complications from COVID-19 and needed to be admitted. Patients were boarded more frequently, fewer beds were available, and EDs were vastly overwhelmed. Overall, COVID-19 exacerbated pre-existing challenges emergency medicine faced for years.
Ethical Issues
Prior to the COVID-19 pandemic, over 90% of EDs experienced significant stress, which pushed them beyond their breaking points. When boarding–a temporary coping mechanism–is implemented, the fundamental principles of privacy and dignity are often ignored. Privacy, in this context, is the freedom from unwanted exposure and intrusion, both physical and informational. Dignity is the respect for each person's inherent worth, ensuring their autonomy, privacy, and bodily integrity are upheld. These infringements are not the fault of physicians or other providers because boarding is an unfortunate necessity to address excessive demands. Yet, for the patient, boarding can strip the legitimate expectation to receive care in a confidential and respectful setting. This may instill fear and self-consciousness in patients as they receive treatment while lying in bed under the gaze of other people. Consequently, their dignity is harmed as they are exposed during treatment and left feeling like an afterthought.
Furthermore, boarding causes patients to endure discomfort for prolonged periods of time. Beneficence is a core bioethical principle that emphasizes the obligation to act in the patient's best interests and minimize harm. Boarding directly contradicts this principle by leading to negative patient outcomes: delays in antibiotic administration, delays in pain medication administration, delays in CT results, lower patient satisfaction, and higher complication rates for cardiovascular events. At times, extremely ill patients who need urgent intervention will leave without being seen (LWBS) due to frustration from waiting. All of these factors contribute to the fact that boarded patients are a group with higher inpatient lengths of stay, morbidity, and mortality–clear violations of beneficence.
Unlike other departments in the healthcare system, the ED is unique in that it offers nearly universal care access. It aims to treat patients regardless of insurance status or ability to pay and serves an essential societal role. However, there are limits to how much the ED can accommodate. When these limits are pushed beyond their breaking point, concerns over distributive justice arise. Individuals from economically disadvantaged backgrounds who lack access to primary care rely extensively on EDs. Some people have no option but to go to the ED to be seen by a physician for non-urgent cases. Under these circumstances, overcrowding worsens the unequal allocation of resources. Lower-income individuals and families who have no other option but the ED are disproportionately affected by delays, inadequate care, and prolonged wait times. This demographic is at greater risk of experiencing poorer health outcomes, increased mortality and morbidity rates, dissatisfaction with care, and mistrust of the healthcare system.
Potential solutions
Several steps could be taken to address ED overcrowding and boarding patients. Solutions to this problem can be divided into two categories: micro-level and macro-level strategies.
Micro-level strategies are designed to be applied at the level of the ED. One idea is to use fast-track paths for non-urgent situations, directly transferring patients from triage to specialist physicians and expediting treatment. EDs can send patients to inpatient specialists or outpatient treatments to help reduce overcrowding. Once patients visit outpatient settings, they can self-monitor and proceed to home care. This method can increase the quality of care and patient satisfaction, especially among the elderly. Lastly, integrating ethical AI and machine learning in triage may help predict patient diagnostic and hospitalization needs. Utilizing technology can allow for proactive control of throughput and resource allocation.
At the macro level, strategies are intended to be applied at the hospital system level. Standardizing admissions with an electronic signature program can reduce delays and increase efficiency between corresponding physicians. Furthermore, reverse triage – identifying stable hospitalized patients who do not require further treatment – can increase the number of safe discharges and free up inpatient beds. Likewise, early discharge with proper collaboration with out-of-hospital structures– hospices, retirement homes, and rehabilitation centers– can reduce boarding and hospital strain. Lastly, post-discharge telemedicine can help educate patients and prevent premature returns to the ED. These macro-level tactics are intended to maximize hospital resources, improve patient flow, and lessen the adverse systemic effects of overcrowding.
Ultimately, addressing ED crowding requires an interdisciplinary approach. Solutions must involve the engagement and commitment of hospital leaders along with stakeholders in the insurance and government sectors of health care. Through large-scale collaboration across all three sectors, we must find a way to develop sustainable strategies to mitigate overcrowding. Above all, it is crucial we ensure the well-being of both patients and providers in emergency care settings and strive for greater equity in health care delivery for everyone.