Intended for healthcare professionals

Head To Head

Is “boarding” appropriate to help reduce crowding in emergency departments?

BMJ 2015; 350 doi: (Published 28 April 2015) Cite this as: BMJ 2015;350:h2249
  1. Adrian Boyle, consultant emergency physician, Cambridge University Hospitals Foundation Trust, Cambridge, UK,
  2. Peter Viccellio, attending emergency physician, Stony Brook University Hospital, New York, USA,
  3. Chris Whale, consultant physician and clinical director, Acute Medicine Business Unit, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
  1. Correspondence to: A Boyle boylea{at}, C Whale chris.whale1{at}

Moving patients from full emergency departments to corridors outside full wards is safe and necessary when accommodating new emergencies, say Adrian Boyle and Peter Viccellio. But Chris Whale warns of the danger in simply displacing the problem and wants a more comprehensive response to inefficient patient flow

Yes—Adrian Boyle and Peter Viccellio

Which is better: having multiple unassessed patients waiting in ambulances outside a full emergency department or having one or two selected, assessed, and treated patients waiting in the corridor of their final but full destination ward? We think the latter.

An emergency department’s full capacity protocol may involve sending assessed patients to wait in the corridors of final destination wards before a bed is available. This “boarding,” which is recommended by the UK Royal College of Emergency Medicine,1 is used in a small number of UK hospitals but occurs more widely in North America. Boarding has been widely, inaccurately, and negatively reported in the UK press2; for this reason hospitals may not publicise the practice, and data on its prevalence are limited.

Problems with crowded emergency departments throughout the United Kingdom last winter were well publicised. Crowding is associated with increased mortality and poor patient and staff experience: for example, a study in California concluded that emergency department crowding was associated with 300 excess deaths in 2007.3 4 5 And several UK hospitals have declared crowding a “major incident,” in which ambulance trusts reported an increasing lack of capacity that delayed the offloading of patients, with a consequent reduced ability to attend emergency calls.

Emergency departments can become crowded for many reasons, but a lack of inpatient bed capacity and the resulting “exit block” from the emergency department is usually a key factor. A full emergency department usually reflects a full hospital, but experience shows that the coordination …

View Full Text

Log in

Log in through your institution


* For online subscription