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Crowding and boarding pediatric emergency departments (ED) is an ongoing problem associated with a mismatch in resources and patient care demands. ED boarding can be defined as a patient admitted to an inpatient unit who remains in the ED. ED boarding occurs when there is limited availability of inpatient bed space – either due to patient volume or decreased staffing. ED boarding is associated with adverse events, and increased mortality1. Few studies address the impact of inpatient strategies on ED boarding3,4. The objective of our study was to evaluate hospital-based strategies within a single institution and their effect on ED boarding times.


This study was performed at an urban, academic, tertiary-care level 1 trauma center in Kansas City, Missouri. We performed a retrospective analysis of ED boarding times in 2022-2023. Data of total patient volume, and ED boarding patient length of stay (LOS) from January 2022 – September 2023 were collected through the hospital EMR and GE informatics. We compared ED boarding LOS total counts/month before and after implementation of institutional changes, accounting for total ED volume. ED boarders were defined as patients admitted to an inpatient hospitalist or ICU team who remained in an ED room longer than 1 hour. The inpatient strategies began in August 2022 improving communication with ED and floor staff, determining patient medical and social needs for discharge, projected discharge dates, and a rapid room turnover protocol.


ED patient volume ranged from 6,800-8,000/month and a peak of 12,000 in November 2023. The ED boarding volume decreased from 142 patients in November to zero from January onwards. There was an increase to 40 patients boarded in March 2023. Data up to September 2023 show a continued reduction in ED boarding patients while controlling for total ED volume.


ED boarding volume decreased after implementation of the hospital-based changes with similar total ED patient volume. Based on our institutional data the inpatient-based systems changes improved communication, planning, and room availability. These changes are achievable and can be implemented in a short period with a reduction in ED boarding, further supporting that ED boarding is a result of inpatient and systemic challenges. The study is limited in its evaluation as more data is needed to compare peak ED visit months and to more closely analyze the impact of the changes.

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Institutional Pilot Changes Lead to a Reduction in Emergency Department Boarding Patients