UMEM Educational Pearls

Settings: this is a meta-analysis of 17 observational studies about boarding of critically ill patients in US Emergency Departments. All studies were from urban, academic centers.

Participants:

• There was a total of 407,178 patients, 194,814 (485) were boarding vs. 212,364 (52%) non-boarding patients.
• 355,86 (87%) patients were at centers with the presence of a resuscitation service.
• Ther was a mixture of critical illnesses: trauma (29.4 %), medical conditions (29.4 %) and mixed critical illness (41.2 %).

Outcome measurement: all cause mortality, as reported by the authors of the original studies.

Study Results:

• Overall, boarding patients were not associated with higher mortality, than non-boarding patients (Odd ratios 1.06, 95 % CI 0.94–1.19 p=0.383).
• Boarding patients were not associated with longer hospital length of stay (mean difference 0.38 days, 95%CI 0.94-1.50, P=0.51).
• However, among subgroup analyses, boarding patient population with mixed critical illnesses was associated with higher odds for mortality (OR 1.2, CI 1.04–1.4, p = 0.02 ) and longer HLOS (difference = 1.9, 95 % CI 0.81–3.1, I2 = 0 %, p = 0.001).

Discussion:

• All studies were observational so there was risk of bias and there was a presence of a small publication bias. This means that there were a few unpublished studies out there that showed that Boarding patients might have better outcomes.
• The findings that patient population with mixed illnesses were associated with higher odds for mortality, compared with Trauma-only or medical-only patients, might suggest that ED are not well equipped to take care of a wide spectrum of disease states. We seem to do better with populations with protocols such as sepsis, stroke, trauma.
• There was no clear consensus about how researchers approach this topic. A few studies did not even report their patient populations’ age (I cannot understand how these got published). Researchers used different thresholds for boarding, likely reflecting their institutional variabilities. There was quite a significant heterogeneity about patients’ acuity: some studies used SOFA, others used mSOFA.
• All of the studies were from urban academic centers so their results may not be applicable to non-academic centers which may not have many boarding issues

Conclusion: 

Critically ill patients boarding in the U.S. Emergency Departments were associated with a non-statistically signi?cant increase in odds of mortality and hospital length of stay compared to non-boarded patients

References

Htet NN, Walker JA, Jafari D, Rech MA, Hintze T, Moran M, Bai J, Dinh K, Essaihi A, Wilairat S, Huddleson B, Tran QK. Outcomes of boarding critically ill patients in U.S. EDs: A systematic review and meta-analysis. Am J Emerg Med. 2025 Oct 17;99:339-347. doi: 10.1016/j.ajem.2025.10.036. Epub ahead of print. PMID: 41151219.