# ED Boarding of Older Adults: Risks and Opportunities About This Podcast Emergency department (ED) boarding is one of the biggest challenges the ED faces. ED boarding refers to the practice of holding patients in the ED who have already been admitted to the hospital while they wait for an inpatient bed to become available. Any patient is at risk of being boarded, but older adults are disproportionately affected and boarding in this population is associated with a sequelae of unfavourable outcomes, including delirium and deconditioning. Although it has been problematic for decades, in recent years ED boarding has significantly worsened and in light of a growing ageing population it is unlikely to resolve without appropriate intervention. In this GEMCast episode, Dr. Maura Kennedy, MDH, MPH, joins host Dr. Christina Shenvi to discuss trends and risks of ED boarding, and strategies to minimise the harms associated with ED boarding of older adults. Dr. Kennedy is the chief of geriatric emergency medicine at Massachusetts General Hospital in Boston and is part of the GEDC adjunct faculty. She has expertise in ED delirium and has recently collaborated on a study evaluating the association between delirium and agitation with ED boarding. Play the Episode Tune in to today’s episode to gain insight into how to approach this pressing issue in your ED. https://youtu.be/ezDRHcux6zY Subscribe on YouTube Subscribe on iTunes Key Points While there is no set time frame defining ED boarding, after 3-4 hours following admission clinicians might begin to consider that patient as being boarded and after 8-12 hours this is regarded as prolonged boarding, associated with even greater harms. Domain 3 of the recently introduced Age-Friendly Hospital Measure states that the target for total ED length of stay (LOS) should be under 8 hours and the target for ED boarding should be under 3 hours. An accumulation of factors contributes to the demand-capacity mismatch of inpatient beds that leads to ED boarding. Inadequate space in discharge settings. The growing population of older adults and more complex patients. ED staffing shortages. ED boarding creates a knock-on effect, as delays to inpatient care will impact newer ED arrivals. Functional decline, delirium, and deconditioning, as a result of ED boarding, all lead to an increase in inpatient LOS, and thus decrease bed availability. There are significant harms associated with ED boarding in older adults. A longer ED LOS is associated with higher risks of delirium, adverse outcomes, increased inpatient LOS, and increased mortality. Some interventions to reduce the harm of boarding for older adults in the ED may involve: Prioritising admission in vulnerable patient groups, such as those with functional or cognitive impairment. Progressing care while in the ED and ensuring critical medications (eg. Parkinsons drugs, antibiotics) are administered during boarding. Normalisation of function including mobilisation, adequate hydration, and regular meals. Modifying the environment to allow for rest and a normal circadian rhythm. Related & Mentioned Resources Below are the studies mentioned in this episode which you may find helpful. JAMA | November 6, 2023 Overnight Stay in the Emergency Department and Mortality in Older Patients A cohort study of French patients over 75 investigating the relation between an overnight stay at risk of inpatient morbidity and mortality. One overnight stay in the ED was associated with a 39% higher risk of death. View Article JAMA | June 11, 2024 Boarding Duration in the Emergency Department and Inpatient Delirium and Severe Agitation A retrospective cohort study Dr. Kennedy collaborated on, evaluating ED boarding duration with development of inpatient delirium or agitation. Longer ED boarding duration is associated with an increased risk of developing delirium or severe agitation and need for physical or chemical restraint during inpatient stay.   View Article JAMA | June 30, 205 Prolonged Emergency Department Stays for Older US Adults A cross-sectional study analysing data regarding ED LOS and prolonged boarding in older adults across the US between 2017 and 2024. From 2017 to 2024 the percentage of admitted patients who boarded over 3 hours increased from 22% to 36%, and the percentage of patients with ED LOS over 8 hours increased from 12% to 20%. Notably, this effect was amplified in academic hospitals where ED boarding over 3 hours went from 22% to 36%, and prolonged ED LOS increased from 19% to 30%. View Article Emergency Medicine Clinics of North America | February 17, 2025 Boarding in the Emergency Department: Specific Harms to Older Adults and Strategies for Risk Mitigation Dr. Kennedys publication providing an overview of the causes, epidemiology, and adverse effects of ED boarding. It also highlights recommendations for clinical practice to minimise the harms. View Article AGS | May 14, 2025 Hallways Feel Like Homelessness: The Geriatric Boarder Experience A qualitative study focused on the subjective experience of older adults who had boarded for over 4 hours. View Article JAMA | June 30, 2025 Addressing the Hospital Boarding Crisis in the US—Time to Act An article by Dr. Kennedy. View Article Next, listen to Delirium, Agitation, and the Role of POCUS in Older Adults in the ED with Dr. Geoff Comp. Play Episode TOOLKIT | December 18, 2025 Addressing Boarding in the Geriatric ED This toolkit provides tools, recommendations, guidelines, and educational resources for EDs to implement processes that address the problem of boarding. It contains essential background and real-world examples of successful boarding protocols and a slide deck presenting the financial and patient-centred benefits of boarding reduction practices. Explore Toolkit View All Boarding Resources >