UCLA physicians tell Los Angeles City Health Commission ED boarding raises mortality, harms training

Two UCLA emergency physicians told the Los Angeles City Health Commission that prolonged boarding of admitted patients in emergency departments is causing measurable harm to patients and undermining the training of future physicians.

At a commission meeting, Hashim Zicree, assistant professor of emergency medicine at UCLA, said ED boarding ‘‘is emblematic of health-system dysfunction’’ and cited research linking boarding to worse outcomes. ‘‘There’s a 5 percent increased mortality for patients who board in the emergency department,’’ Zicree said.

A second UCLA physician (an emergency physician and longtime medical communicator who said he had trained at USC and UCLA) described a common scenario in which admitted patients occupy ED beds because inpatient units lack available staffed beds. ‘‘Imagine if LAX closed three and a half of its four runways and parked planes on the runways that are closed,’’ the presenter said. ‘‘That’s the way to describe what’s happening every day in emergency departments across the country.’’

Why it matters: the presenters told commissioners that boarding affects three groups simultaneously — the patients sitting in ED hallways while awaiting inpatient beds, the new patients who cannot get timely evaluation because ED capacity is filled, and trainees who learn to practice ‘‘shallow’’ medicine under time and space pressure. Zicree and his colleague gave examples and cited both local pilots and national policy experiments that they said have reduced boarding or its harms.

Key findings and local pilots - The UCLA presenters described an ‘‘optimizer’’ pilot funded by a donor that placed an additional senior physician in the ED to coordinate care and speed disposition. They said the pilot reduced door-to-doctor time during busy periods from roughly 70–80 minutes (typical at many academic centers) to about five minutes, and returned ‘‘over 90%’’ of paramedic crews to service within 20 minutes. - The presenters noted that some hospitals have reduced ED boarding by changing surgical scheduling (‘‘surgical smoothing’’) so that elective surgery does not concentrate high-reimbursement cases on particular days, and by using ‘‘hallway boarding’’ on inpatient units so admitted patients are moved out of the ED even when fully staffed inpatient rooms are not available. - The speakers recommended expanding ‘‘hospital at home’’ programs where CMS reimbursement permits, and studying alternative payment models such as Maryland’s global budgeting pilots that give hospitals a fixed budget for the year to incentivize prevention and better flow.

Research and system drivers The presenters described boarding as a result of modern hospital financing and operational incentives: hospitals run with little excess capacity, prioritize high-reimbursement surgical activity, and often lack staffing (especially nurses) to open physical beds even when they exist. Zicree said the systems that successfully manage flow have intense, daily senior-executive involvement, cross-unit discharge planning and data-driven ‘‘czars’’ who review who is waiting in the ED and why.

Risks to patients and trainees The presenters gave patient-level examples, including a described case in which unnecessary testing led to harm. They warned that trainees who mainly work in crowded ED settings learn to rely on ‘‘carpet-bomb’’ ordering rather than careful bedside evaluation, a pattern the presenters said will multiply poor outcomes over time.

Commissioner questions and follow-up Commissioners asked about specifics: how much EMS ‘‘wall time’’ results from boarding, whether direct-admit patients now arrive in the ED because of federal medical-screening rules, and the local effect of nursing shortages. Presenters said that at academic centers about 35–40% of boarded patients had been intended as direct admits but ended up in the ED when inpatient capacity was not available. They also described the county’s emerging policy tools to hold hospitals accountable for excessive wall time and suggested the commission could push for clearer, patient-centered access metrics.

Votes at a glance - Annual elections: Motion to elect Dr. Calfani as president, Commissioner Aussie as vice president and Dr. Lemos as second vice president. Seconded; roll call vote recorded as six in favor, approved. - Honorary title: Motion to permit use of an honorary title (‘‘president emeritus’’) for past presidents of the commission as an honorific (not a commission authority). Seconded; unanimous approval (6–0). - Bylaw change process: Motion to place a bylaw amendment on the next meeting agenda to create a formal ‘‘president emeritus’’ bylaw entry (the change would require future bylaw action). Seconded; unanimous approval (6–0). - Annual report: Motion to adopt the 2024–25 annual report with three small edits to a housing section and photo/bio updates for commissioners; seconded and approved unanimously (6–0).

What the meeting did not decide The presentation was informational; commissioners did not adopt new city policy or funding in the meeting. Presenters urged a mix of operational pilots (optimizer positions, hallway boarding upstairs, surgical smoothing) and payment-model experiments (hospital at home, global budgets) but emphasized that large-scale resolution depends on systemic financing changes beyond local authority.

Next steps mentioned Presenters and commissioners discussed follow-up research and outreach. Commissioners asked staff to obtain the presentations’ cited studies and to invite other system stakeholders (e.g., LA County EMS, local hospital system leaders) for further briefings. Presenters left the meeting after their Q&A.

Ending Commissioners thanked the presenters and moved to other agenda items, including annual elections and bylaws business. No formal commission directive on ED boarding was adopted at the meeting.