Though more than 10 years ago, I still remember the indignity of spending hours being “boarded” in the hallway of the emergency department at a highly regarded academic medical center in Chicago. Wearing only a flimsy cotton gown, I sat on a gurney lined up against the wall in the hallway (commonly referred to as a “hall bed”) waiting for my lab results, which would take a few hours to arrive.

My prime spot across from the nurse station allowed me to watch the frenzied activity of the ED and even hear a physician giving “confidential” instructions to the man next to me. I finally spent the night as an outpatient in the observation unit once a bed opened.

Unfortunately, my experience isn’t that uncommon. According to the American College of Emergency Physicians (ACEP), boarding—patients held in the emergency department after they’ve been admitted as inpatients or because no beds are available—is the primary cause of ED overcrowding.

Between 1975 and 2015, 30 percent of U.S. inpatient beds were eliminated due to many factors such as hospital closures and conversion to private rooms. ACEP reports that more than 62 percent of patients admitted through the ED are boarded there for at least two hours—and these patients are most likely to move into a hallway to make way for new patients

Six years ago, the Joint Commission established the “Patient Flow Standard” that recommended that boarding time not exceed four hours “in the interest of patient safety and the quality of care.” The four-hour time frame is not a requirement for Joint Commission accreditation because it suggested that, in some cases, meeting that time may be out of the hospital’s control.

So how can this issue be addressed and are there supporting physical solutions? Many hospitals are greatly increasing ED capacity, some to house these boarding inpatients, but this is a costly endeavor, especially in a department operating 24/7. The ED staff doesn’t want to take care of inpatients along with their already heavy workload.

Operational improvements can help. The Studer Group, a healthcare operational consultant, suggests better bed management strategies such as modifying times for elective admissions, improving discharge procedures to create open beds earlier in the day, and “Red Modes” that trigger hospital-wide action plans to expedite services when the ED is at capacity.

For instance, patients may be temporarily moved to a patient room on a specialized unit that doesn’t meet their diagnosis until an inpatient bed is available. Some hospitals are implementing “reverse triage” where inpatients are discharged that have the lowest acceptable rate of potential adverse outcome, which can create additional bed capacity in a short amount of time.

Other facilities have addressed overcrowding in the ED by boarding patients on the inpatient floor, instead of the ED, with research showing most patients prefer that environment to the ED thanks to less noise, more privacy, and great comfort. Hall boarding patients on inpatient units has been shown to decrease boarding times significantly, too. Once inpatient staff is responsible for the care of boarded patients, they work to discharge others and prepare rooms sooner to accommodate them.

Still, the practice of boarding patients in corridors shouldn’t be a long-term solution to addressing the problem of overcrowding in the ED. As healthcare designers, how many EDs have you seen with large number signs in the hallways designating hall bed locations, even soon after opening? One of my clients told me they installed ceiling-mounted televisions in the inpatient corridor to keep their boarding patients occupied while waiting to be moved into a room.

For all our industry’s talk about patient experience and the ideal patient room, we haven’t addressed this reality in our guidelines or our designs, which raises a few questions:

  • Should we create more observation or short stay units to increase capacity on inpatient floors?
  • Should we position a one-or two-patient open holding area directly visible from the nurses’ station on inpatient units?
  • Should more of our private patient rooms be sized to accommodate two beds to create surge capacity?

Until operations are in place to reduce or eliminate boarding, we need to develop proper settings to house these patients and not just ignore the problem.

Sheila Cahnman, FAIA, FACHA, LEED AP, is president, JumpGarden Consulting, LLC. She can be reached at