There’s a longstanding notion in healthcare that patients with low-acuity conditions are a key driver of overcrowding and boarding in emergency departments (ED) — one that emergency medicine experts describe as a misconception that distracts from real solutions.
“I’m not really sure how that myth has been given any legs,” Michael Bublewicz, MD, vice president and chief medical officer of emergency medicine at Houston-based Memorial Hermann Health System, said on a recent episode of the Becker’s Healthcare Podcast.
For years, efforts to ease strain on emergency departments have centered on the idea that healthcare providers should do more to educate patients on when it is appropriate to visit the ED versus an urgent care clinic, or that more urgent care centers should be built near high-volume EDs.
While well intentioned, emergency medicine experts say these efforts are ineffective because they are solely focused on ED input factors, rather than systematic issues across the broader healthcare delivery ecosystem.
“Programs to keep low-acuity patients out of the ED do not reduce boarding because low-acuity patients are rarely admitted to the hospital,” said the Agency for Healthcare Research and Quality (AHRQ) in a recently published report summarizing key outcomes from its October 2024 summit on ED boarding. The event brought together hospital and health system executives, patients, clinicians and policymakers who emphasized that input-focused interventions alone are ineffective at addressing the systemic throughput failures and misaligned incentives that drive boarding.
The perception that low-acuity patients tie up resources in EDs also ignores the reality that today’s health systems are increasingly caring for patients with complex medical needs. In the U.S., utilization rates of emergency services are highest among homeless individuals, nursing home residents and infants under the age of 1, according to an analysis of national data from the Emergency Department Benchmarking Association (EDBA). Demand for emergency services is only expected to grow as the nation’s population ages.
Estimates vary on the exact share of ED visits that are low acuity, but analyses from EDBA — which pulls data from more than 1,000 emergency departments across the country — indicate these cases account for a relatively small share of overall visits. National data consistently indicate that the share of high-acuity and medically complex ED visits has been rising over time, reflecting broader demographic and clinical trends.
“The low acuity folks that present to EDs are pretty few and far between and they tend to present in hours where access isn’t available,” such as weekends, late-nights and holidays, Dr. Bublewicz said.
James Augustine, MD, vice president of the EDBA, said that EDs today are caring for a much different patient population than in decades past.
“Our ED patients are increasingly senior and they’re increasingly medical – meaning that injured patients occupy less and less of the ED volume,” he told Becker’s. “In my career, we used to see a lot of industrial injuries, sprained ankles and lacerations. The injury population is very much shrinking.”
At AHRQ’s summit, stakeholders unpacked several systemic factors that drive ED boarding, including reduced inpatient bed capacity, financial incentives that prioritize high-revenue surgical cases, administrative issues, and burdensome payer requirements that lead to delays in discharging patients.
Emergency medicine leaders say addressing these root causes requires coordinated efforts that go beyond ED-specific fixes. Hospital-led strategies proven to be effective include smoothing elective surgery schedules across the full week to even out inpatient demand, establishing discharge lounges and protocols to streamline patient flow, and using inpatient bed managers to expedite bed assignments.
Beyond hospital-level efforts, leaders emphasized the need for broader policy changes, including revised payment incentives, public reporting of boarding metrics, development of real-time regional bed tracking systems and expanded access to timely behavioral health services.
