Dr. Jonathan Olshaker is former chairman of the emergency department of Boston Medical Center and professor emeritus of the Boston University Chobanian and Avedisian School of Medicine. Dr. Scott Weiner is an associate professor of emergency medicine at Harvard Medical School and director of the emergency department-based Substance Use Disorder Initiatives at Brigham and Women’s Hospital and Massachusetts General Hospital.
A trip to the emergency department is stressful. Patients with chest pain, trouble breathing, headaches, trauma, or other complaints are worried that something serious is wrong with them.
Already nervous and scared patients are routinely met with packed waiting rooms, long waits to get triaged by nurses, and even longer waits to be seen by physicians. There is a high likelihood of being evaluated and staying in a hallway with no privacy or basic comforts for hours or, if admitted to the hospital, even days. They often will experience delays in pain control and frequently are witness to violence against health care workers.
This is not a reflection of the emergency department physicians, nurses, and staff who do an outstanding job of evaluation, diagnosis, and treatment as well as comforting and reassuring their patients. Obviously life-threatening cases get immediate care. But the present conditions of almost every emergency department make the already tough task of providing safe and compassionate care for patients with potential serious illness or injury increasingly difficult.
The main cause of emergency department overcrowding is boarding, or the time between when the clinical team decides to admit a patient to the hospital and when the patient actually leaves the emergency department for that inpatient bed. Boarding has for too long been accepted by hospital administrators as the “new normal” because it is ubiquitous and extremely difficult to solve.
Massachusetts’ Health Policy Commission, an independent agency that monitors health care costs, documents in its March 2026 report that Massachusetts is the second worst state for average time spent in the emergency department, trailing only Maryland. Waits for inpatient hospital beds can last more than 24 hours, and for patients who need to be transferred elsewhere, the wait can sometimes last days or even weeks. Strained community hospitals sometimes can’t transfer critically ill patients because tertiary care and academic hospitals are already full. Some patients who visit the emergency department leave without being seen at all.
Over a decade of peer-reviewed research has documented the association of boarding with increased numbers of medical errors, treatment delays for time-sensitive conditions, patient frustration, and death. Emergency department overcrowding is also associated with higher staff burnout, which in turn contributes to the vicious cycle of increased medical errors and staffing shortages.
Some of the major causes of boarding are fewer staffed inpatient beds, the need to keep almost all hospital beds full to sustain thin hospital financial margins, shortages of rehab and other post-discharge facilities for patients who need more time to recover, and the purposeful prioritization of more lucrative elective admissions, often for procedures.
There is no simple or single fix to emergency department boarding. At the federal level, regulators such as The Joint Commission and Centers for Medicare and Medicaid Services must continue to address the crisis through measurement, reporting, rewards, and penalties. But statewide legislative efforts combined with increased focus from the Massachusetts Department of Public Health and health care systems are also necessary to address financial drivers and implement best practices. Legislative levers that can help are mandating transparent reporting, requiring all hospitals to have “full capacity response plans,” expanding downstream capacity, building behavioral health alternatives, and realigning payment and oversight so hospitals are rewarded for flow, not chronic over-occupancy.
Although it will not be simple or easy, Massachusetts can become a model state by addressing this challenge. We propose six concrete steps:
1. Create real-time all-cause and behavioral-health boarding dashboards, as has been done in neighboring Connecticut.
2. Evaluate, audit, and enforce hospital full-capacity protocols and escalation plans with penalties for deviations.
3. Fund and/or incentivize workforce and bed expansion across inpatient, post-acute, and community settings. This can be aided by measures like the recently passed law to expand primary care.
4. Strengthen MassHealth and insurer payment policies that support behavioral health crisis services and rapid placement.
5. Support regional bed-availability and transfer-coordination systems.
6. Ensure access to post-acute care to improve outflow from our hospitals.
Massachusetts legislators can reduce boarding by changing incentives, expanding capacity, and requiring accountability across all health care systems. The consequences of not doing so will lead to continued long emergency department waiting times, poor patient experience and satisfaction, burnout of health care workers, and most importantly, worse health outcomes.