Boarding in Emergency Department Hallways Circa 2025: Why Older Adult Patients Deserve Better

Abstract

Over the past three decades, the hospital practice of emergency department (ED) boarding and the crowding that results from it have been regularly and consistently named as a public health crisis. Yet, despite repeated stakeholder discussions and engagement, no broad policy solutions nor durable, structural changes in ED care have addressed the ED boarding crisis and its negative effect on patient care and outcomes in a meaningful way. Recent evidence has shown that the problem has worsened substantially since the onset of the COVID-19 pandemic [1].

A missing element in these repeated calls for action is the lived experience of geriatric ED boarders. A study in this issue of the Journal of the American Geriatric Society performed at the Massachusetts General Hospital titled “Hallways Feel Like Homelessness,” fills that gap [2]. It offers an insightful look into the experience and perceptions of geriatric ED boarders—ill older adults admitted to the hospital who experienced long delays in the ED to be transferred to their inpatient beds.

The study presents a qualitative analysis of 26 patients aged 65 and older who boarded in the ED for at least 4 h. The mean age of participants was 77 years. Through their own words, the authors present a window into a world where stretchers become beds, noise replaces rest, and naked vulnerability is on display. The authors found that patients were not just distressed by their long waits. Geriatric ED boarders felt powerless, exposed, and forgotten. For some, boarding in a hallway was likened to being homeless or imprisoned. One participant described the experience as being “in exile.” The irony of this sentiment should not be lost when considering the origin of the word hospital, from French and medieval Latin, meaning a place of reception for guests, with the words, hotel and hostel, coming from the same origin. Given this origin, the lack of hospitality in the hospital described in this study is disturbing.

The hospital practice of ED boarding is not just about a lack of creature comforts. Nearly 20 years of literature have found the practice to be directly harmful to the ill and injured—linked to increased delirium, longer hospitalizations, and higher mortality [3-5]. The deleterious effects are magnified in vulnerable older adults [6]. The voices in this study tell us something the quantitative study data cannot: how older patients internalize these conditions, what they observe, and what they fear. Geriatric ED boarders are starkly aware of being placed in locations that lack basic safety features—no call bells, no privacy, and sometimes not even food.

A notable study finding was that participants did not blame their doctors or nurses. They reserved their criticism for the physical environment and the hospital systems that tolerate it. This distinction is vital. The healthcare workforce is compassionate and dedicated. Yet compassion does not compensate for a broken system. Clinical care that follows established guidelines delivered in a chaotic corridor is still just hallway care.

Boarding is often framed as an ED issue. It is not. It is a hospital throughput problem, a staffing problem, and a resource allocation problem [7]. Hospitals that prioritize their elective surgeries over acutely ill ED patients exacerbate boarding [8]. Nursing shortages and inpatient bed closures widen the gap. EDs are the pressure valve for a system that no longer has slack.

The findings of this study underscore that improving the care experience for geriatric ED boarders requires both a combination of a structural overhaul in the incentives hospitals face as well as the rapid promotion of interventions to improve the patient experience and mitigate quality issues during the hospital admission process. Many highly effective interventions exist to reduce boarding that can be implemented throughout the hospital [9]. Yet many hospitals have not implemented them nor effectively addressed their boarding problem.

The study found that one specific, targeted solution can yield meaningful change: a dedicated ED boarder unit, which was present in the ED during the study period. There, a quieter, more structured environment with lights dimmed at night, access to call bells, and attentive staff restored patient dignity and agency, to some degree. This suggests that modest environmental improvements in the ED could have outsized impacts on patient experience and well-being. Study participants consistently viewed this approach as more humane and tolerable than lying in hallway spaces.

Another area highlighted in the study was the idea to prioritize older adult patients for available beds, specifically those who are more likely to be harmed by the ED boarding. Realigning hospital reimbursement for older adults could incorporate validated assessments of frailty, cognitive impairment, and clinical acuity. This aligns with geriatric medicine principles and was strongly endorsed by participants in the study. With the Centers for Medicare and Medicaid Services (CMS) Age-Friendly Hospital Measure now promoting frailty and cognitive screening as one element of care, hospitals may have more of a regulatory impetus to use these data not only for documentation, but also for actionable triage decisions.

Broader scale, policy interventions are needed to drive accountability and ultimately durable change in the rising boarding in America's hospitals. Public reporting of boarding times is one idea that may drive action. Metrics of boarding are now being piloted by the Leapfrog Group. Additionally, accreditation standards that prohibit prolonged hallway care, and payment models that incentivize efficient throughput (rather than elective volume) could shift hospital priorities. CMS could consider time-based reimbursement penalties for excessive ED boarding, especially for high-risk populations like older adults.

Finally, we cannot escape the ethical dimensions that emerged from this study. If we accept that older adults are more likely to be harmed by boarding and less able to advocate for themselves, then continuing the status quo becomes indefensible. The hallway becomes not just a holding zone but a mirror reflecting our system's values. Most hospitals' mission statements emphasize the value of respect, underscoring the importance of treating patients with dignity. The practice of ED boarding systemically erodes such values.

Study participants were stoic, even forgiving of this. But stoicism should not be confused with acceptance. As one participant put it: “That's the way it is… but it's not really a good experience.” We owe our patients more than the inevitability of indignity.

As health systems work to address boarding and improve efficiency, we must keep geriatric voices front and center. This study reminds us that people are more than patients—they are observers, critics, and philosophers of their own care. These findings present multiple new themes and factors that deserve hypothesis-generating quantitative analysis. Their insights are not soft data; they are moral guideposts in a system too often built for convenience and economics rather than compassion.

J.M.P. wrote the initial draft of the editorial. R.M.R. and E.R.M. provide copyedits. All authors approved the final manuscript.

The authors declare no conflicts of interest.

This publication is linked to a related article by Perelman et al. To view this article, visit https://doi.org/10.1111/jgs.19518.