Hospital Floor Hallway Boarding: A Systematic Review of Outcomes

ABSTRACT

Objectives: The prolonged boarding of admitted patients in the emergency department (ED) increases crowding, a significant challenge for hospitals. Some hospitals have implemented hallway boarding by placing patients in inpatient hallways when standard rooms are unavailable. However, the impact of hallway boarding on patient preferences, clinical outcomes, and patient safety remains uncertain.

Study Design: Systematic review and meta-analysis.

Methods: We conducted a systematic review and meta-analysis of studies comparing boarding patients in an inpatient hallway with those in the ED or a standard inpatient room, examining patient preferences, length of stay (LOS), mortality, or safety outcomes. We used predefined criteria to assess study quality and calculated pooled estimates of patient preference using random-effects models.

Results: Eleven studies were included, primarily conducted in the US, with designs ranging from retrospective analyses to surveys of patients, nurses, and physicians. Patient preference was the most studied outcome. Meta-analysis demonstrated that 61% of patients preferred inpatient hallway boarding over ED hallway boarding (95% CI, 50%-71%; P < .001), although heterogeneity was high (I² = 87.4%). Fewer studies reported on clinical outcomes. Inpatient hallway boarding was associated with significantly reduced ED LOS in 2 studies (9.3 vs 13.8 hours; 6 vs 8 hours) and hospital LOS in 1. Mortality, as studied in 3 papers, remained unchanged or decreased significantly. Safety outcomes were mixed.

Conclusion: Inpatient hallway boarding can improve ED throughput, and most studies show patients prefer it to ED hallway boarding. No study has shown increased mortality, but current research is insufficient to draw clear conclusions about quality and safety.

Am J Manag Care. 2026;32(9):In Press

doi:10.37765/ajmc.2026.90013

Takeaway Points

• Emergency department (ED) crowding is prevalent and associated with worse outcomes, notably increased mortality. Prolonged ED boarding of admitted patients contributes to crowding.
• Moving boarding patients from the ED to inpatient hallways can help alleviate crowding. However, the practice’s impact is unclear.
• Our systematic review identified a limited number of studies, most of which were of fair quality. We found that patients preferred boarding in inpatient hallways rather than the ED. Mortality was not increased, but quality and safety outcomes were rarely studied and of poor quality.
• Hallway boarding may seem promising, but we need stronger evidence before making a firm recommendation.

Emergency department (ED) crowding remains a pervasive challenge worldwide, contributing to delays in care and worse clinical outcomes.¹ Prolonged boarding of admitted patients in the ED is a key driver of crowding, straining limited ED resources and exacerbating patient safety risks. Common contributors include rising patient volumes, delays in transferring patients to inpatient units, and a general shortage of available hospital beds.²

In response, some institutions have adopted alternative strategies to alleviate pressure on the ED. One approach involves inpatient hallway boarding, where admitted patients are temporarily placed in hallway spaces on inpatient units when standard rooms are unavailable.³ Notably, the full capacity protocol, first implemented at Stony Brook University Hospital, formalized this practice and has since been adopted by other hospitals in the US and Canada to manage patient surges more safely and efficiently.⁴

Inpatient hallway boarding may offer benefits by expediting the transfer out of the ED and enhancing hospital throughput. However, concerns about patient privacy and dignity⁵ have been raised. It is also unclear how the practice affects quality and safety metrics, such as hospital-acquired conditions. To address this gap, we reviewed the available literature evaluating the effects of implementing inpatient hallway boarding, compared with ED boarding, on patient quality and safety outcomes and on hospital operations.

METHODS

Definition of Hallway Boarding

Hallway boarding is also known as inpatient boarding or floor boarding. It refers to transferring an admitted patient awaiting a hospital room from the ED to a bed in a hospital floor’s hallway. The patient typically stays there until a room is ready.

Search Strategy for Identification of Studies

We collaborated with a medical librarian (AGS) to develop detailed search strategies for each database, aiming to identify studies to include. We reviewed the search terms to ensure accuracy and relevance. The medical librarian developed a unique search for each database. All final searches were peer-reviewed by another librarian according to the Peer Review of Electronic Search Strategies checklist before execution. We searched the following databases: PubMed (1809-present), Embase (1974-present), and Cochrane Central Register of Controlled Trials (CENTRAL; Wiley, 1998-present). We imposed no language or other restrictions on any of the searches. Our exclusion criteria were reviews, expert opinions, and guidelines. We also chose to exclude any gray literature, such as conference proceedings or policy reports, because it did not meet our inclusion criteria: peer-reviewed original studies evaluating specific outcomes related to inpatient hallway boarding.

All database searches occurred on April 26, 2024, yielding a total of 468 citations. The librarian (AGS) removed duplicates using Covidence’s duplicate detection. We imported the search into the Covidence software. eAppendix A (eAppendix available at ajmc.com) provides details of the complete search strategies.

Study Selection, Assessment, and Data Extraction

Four reviewers (SB, KA, RT, and JSR) reviewed the titles and abstracts to identify the relevant articles. Two reviewers (RT and KA) examined the full-text articles to determine whether the studies met the inclusion criteria. When no agreement was reached, a third reviewer (JSR) served as the adjudicator. Two reviewers (RT and JSR) extracted the data using a standardized form. The extracted data included the study title, authors, year of publication, years studied, country, aim, design, setting, sample size, mean age, gender frequency, primary and secondary outcomes, and results. The following reviewers (RT, SB, KA) used the National Institutes of Health (NIH) Quality Assessment of Systematic Reviews and Meta-Analyses to assess the quality of the studies, and 2 reviewers (SB and JSR) utilized the Grading of Recommendations Assessment, Development and Evaluation (GRADE)⁶ approach to assess the quality of the evidence. The study was registered with PROSPERO (CRD42024513583).

Data Analysis and Meta-Analysis

We assembled the extracted data in a standardized database using Covidence. We performed a meta-analysis of the proportion of patients who prefer hallway to ED boarding. We presented the proportions on a scale of 0 to 1 rather than as percentages; 1 corresponded to 100% preference for hallway boarding. The results were displayed as proportions with 95% CIs in each group. I² was used as a measure of heterogeneity, with the following interpretation: I² = 0% to 40%, might not be important; I² = 30% to 60%, might be moderate; I² = 50% to 90%, might indicate substantial heterogeneity; and I² = 75% to 100%, might indicate considerable heterogeneity. The results of this meta-analysis were considered statistically significant at P < .05.

RESULTS

Study Selection

The complete database search yielded 468 studies: 332 in Embase, 123 in PubMed, and 13 in CENTRAL. We removed 109 references, leaving 359 studies to be screened. After the title and abstract review, we excluded 323 studies, and 36 were deemed eligible for full-text review. We excluded 25 studies after a full review, leaving 11 manuscripts in the final analysis. Figure 1 summarizes our study selection results.

Study Characteristics

Of the 11 studies, 8 were conducted in the US, while the remaining 3 took place in Israel, Canada, and Norway. The study design distribution was as follows: retrospective in 3 studies,^4,7,8 a prospective survey of patients in 4,^3,9-11 a phone survey in 1,¹² a survey of nurses in 1,⁵ a survey of physicians and nurses in 1,¹³ and a combination of retrospective and prospective data collection in 1.¹⁴ Respondents in survey studies ranged from 60 to 1222, whereas studies examining length of stay (LOS) and mortality outcomes had significantly larger numbers of included participants, ranging from 297 to 55,000. The proportion of females was reported in 8 of the 11 studies,^{3-5,7,8,11,12,14}and age in 6 studies.^{3,4,7,8,11,12}

Study quality was deemed good for 3 studies,^3,8,10 fair for 7,^{4,5,7,9,11,12,14} and poor for 1,¹³ and the GRADE of the studies was deemed low in 7 studies^{3,4,7-9,11,14} and very low in 4.^5,10,12,13 Table 1 lists each study’s characteristics.

Outcomes

The most studied outcome was boarding preference.^3,5,9-12 In the 6 studies that address this outcome, the proportion of respondents preferring hallway boarding over ED boarding ranged from 42% to 85%, with most studies favoring hallway boarding. The meta-analysis (Figure 2) found that a statistically significant proportion (P < .001), 0.61 (range, 0.50-0.71), favored hallway boarding. The heterogeneity was substantial with I² of 87.4% and a T² of 0.29. Given that Viccellio⁴ was a clear outlier, we ran the meta-analysis without it (eAppendix B) and got an overall prevalence of 0.57 (range, 0.51-0.62). Three studies reported in-hospital mortality,^4,7,8 and none showed an increase in mortality with the implementation of the hallway policy.

The ED LOS was reported in 2 studies.^12,14 Patients going to an inpatient hallway had a shorter ED LOS than those going to a standard room (9.3 vs 13.8 hours; P = .006)¹⁴ and those who boarded in the ED instead of the medical ward (6 vs 8 hours; P not provided¹²). A study⁸ showed a significantly lower hospital LOS in hallway beds compared with standard beds (2.7 vs 3.4 days; P < .001).

Safety of care outcomes was also studied. In one study,⁸ intensive care unit (ICU) transfers decreased from 6.1% to 4.9% (P = .02) and hospital-acquired infections decreased from 4.6% to 3.4% (P = .005) after the institution of the hallway policy.⁸ However, 30-day readmissions were higher in another study (14.45%-15.7%; P = .019).⁷ The time to medication administration was not different between hallway patients and standard bed patients (6 vs 6.6 hours; P = .85). Table 2 summarizes the outcomes and results of each study. We did not perform subgroup analyses due to the limited number of included papers.

DISCUSSION

This systematic review synthesizes evidence from 11 studies examining patient preferences, clinical outcomes, and the safety of care associated with the implementation of inpatient hallway boarding. The findings suggest that hallway boarding may be associated with favorable patient perception. Findings on quality and safety outcomes were mixed.

Four of the 6 studies addressing patients’ preferences favored inpatient hallway boarding. However, substantial heterogeneity in these results (I² = 87.4%) highlights variability across patient populations, study settings, and survey methodologies, which should be carefully considered. The meta-analysis was statistically significant, but the random-effects model CI (0.50-0.71) was close to including the null value, limiting our ability to draw strong conclusions about patient preferences. However, one study by Viccellio⁴ was a clear outlier, and we needed to determine whether excluding it would still show hallway preference. We still found statistical significance with a proportion of 0.57 CI (range, 0.51-0.62) and less heterogeneity (I² = 76.5%). In conclusion, we cautiously interpret the data that, despite concerns about privacy and dignity, patients see the inpatient hallway as a preferable alternative to prolonged ED boarding.

Regarding clinical outcomes, the available evidence suggests that inpatient hallway boarding does not increase in-hospital mortality, which is significantly reduced in one study.⁷ This is reassuring, but the quality of these studies does not permit a definitive verdict. As for the LOS, the ED LOS was consistently shorter for patients transferred to inpatient hallways^12,14 than for those who remained in the ED. The ED crowding literature has shown some association between ED crowding and increased mortality.¹⁵ We can therefore hypothesize that the potential mortality benefit may result from a decrease in ED LOS. Additionally, findings of decreased hospital LOS^7,8 suggest potential system-level efficiency gains, possibly due to reduced delays in care once patients leave the ED. Decreased hospital LOS can reduce ED crowding, providing an additional benefit to implementing hallway boarding.

Safety outcomes were mixed. Lee et al⁸ suggested reductions in ICU transfers and hospital-acquired infections, a possible benefit of earlier transfer from the ED to an inpatient setting. Conversely, Ben Shoham et al⁷ reported a modest increase in 30-day readmissions, suggesting unintended consequences of earlier movement or less comprehensive care in hallway settings. Notably, the time to medication administration¹⁴ was not adversely affected, indicating that basic care processes can be maintained in hallway locations. Most importantly, we conclude that it is not possible to draw solid conclusions about the effect of inpatient hallway boarding on quality and safety from the current published research.

Limitations

This review has several limitations. First, the overall quality of the included studies was modest, with grades ranging from low to very low and NIH ratings of fair for most papers. The predominance of retrospective designs and survey-based methodologies limits the ability to establish causality and introduces the potential for recall bias, response bias, and residual confounding. Second, substantial heterogeneity across study populations, outcomes, and definitions of hallway boarding complicates direct comparisons and limits the generalizability of pooled estimates. Our meta-analysis of patient preferences demonstrated very high heterogeneity, reflecting methodological and contextual variability across studies. Third, key demographic variables such as age, sex, and comorbidities were inconsistently reported, making it difficult to assess whether specific subgroups may have different preferences or outcomes in hallway settings. Fourth, the number of studies that we were able to include was limited to a few small studies, raising the possibility of selection and publication biases. Finally, clinical outcomes, such as mortality, ICU transfers, readmissions, and infection rates, were reported in only a small subset of studies, with mixed results. Important patient-centered outcomes, including perceptions of privacy, dignity, and satisfaction, were not uniformly evaluated. Taken together, these limitations highlight the need for larger, multicenter prospective studies with standardized definitions and robust outcome reporting.

CONCLUSION

Inpatient hallway boarding may offer a practical alternative to ED boarding during capacity constraints, as suggested by patient-preference data. The evidence on quality and safety is lacking high-quality, multicenter prospective studies, which limits our ability to recommend generalizing its implementation and to inform policies that balance efficiency with patient safety and dignity of care.

Author Affiliations: Cooper Medical School of Rowan University (RT, KA, KH, SB, JSR), Camden, NJ; Department of Medicine (KA), Cooper Research Institute (KH), and Center for Hospital-Based Services (SB, JSR), Cooper University Healthcare, Camden, NJ.

Source of Funding: None

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (RT, KA, KH, JSR); acquisition of data (RT, KA, KH, JSR); analysis and interpretation of data (RT, KA, KH, SB, JSR); drafting of the manuscript (RT, SB, JSR); statistical analysis (KH, JSR); and supervision (SB, JSR).

Address Correspondence to: Samer Badr, MD, Cooper Medical School of Rowan University, Education and Research Building, 401 Haddon Ave, Camden, NJ 08103. Email: badr-samer@cooperhealth.edu.

REFERENCES

1. Derlet RW, Richards JR. Overcrowding in the nation’s emergency departments: complex causes and disturbing effects. Ann Emerg Med. 2000;35(1):63-68. doi:10.1016/s0196-0644(00)70105-3

2. Hoot NR, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med. 2008;52(2):126-136. doi:10.1016/j.annemergmed.2008.03.014

3. Richards JR, Ozery G, Notash M, Sokolove PE, Derlet RW, Panacek EA. Patients prefer boarding in inpatient hallways: correlation with the national emergency department overcrowding score. Emerg Med Int. 2011;2011:840459. doi:10.1155/2011/840459

4. Viccellio A, Santora C, Singer AJ, Thode HC Jr, Henry MC. The association between transfer of emergency department boarders to inpatient hallways and mortality: a 4-year experience. Ann Emerg Med. 2009;54(4):487-491. doi:10.1016/j.annemergmed.2009.03.005

5. Pulliam BC, Liao MY, Geissler TM, Richards JR. Comparison between emergency department
and inpatient nurses’ perceptions of boarding of admitted patients. West J Emerg Med. 2013;14(2):90-95. doi:10.5811/westjem.2012.12.12830

6. Guyatt GH, Oxman AD, Vist GE, et al; GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ.2008;336(7650):924-926. doi:10.1136/bmj.39489.470347.AD

7. Ben Shoham A, Munter G. The association between hallway boarding in internal wards, readmission and mortality rates: a comparative, retrospective analysis, following a policy change. Isr J Health Policy Res. 2021;10(1):8. doi:10.1186/s13584-021-00443-3

8. Lee MO, Arthofer R, Callagy P, et al. Patient safety and quality outcomes for ED patients admitted to alternative care area inpatient beds. Am J Emerg Med.2020;38(2):272-277. doi:10.1016/j.ajem.2019.04.052

9. Guthrie BD, King WD, Monroe KW. Parental preferences for boarding locations when a children’s hospital exceeds capacity. J Emerg Med. 2009;53(6):762-766. doi:10.1016/j.jemermed.2007.05.012

10. Walsh P, Cortez V, Bhakta H. Patients would prefer ward to emergency department boarding while awaiting an inpatient bed. J Emerg Med. 2008;34(2):221-226.

11. Garson C, Hollander JE, Rhodes KV, Shofer FS, Baxt WG, Pines JM. Emergency department patient preferences for boarding locations when hospitals are at full capacity. Ann Emerg Med.2008;51(1):9-12.e3. doi:10.1016/j.annemergmed.2007.03.016

12. Viccellio P, Zito JA, Sayage V, et al. Patients overwhelmingly prefer inpatient boarding to emergency department boarding. J Emerg Med.2013;45(6):942-946. doi:10.1016/j.jemermed.2013.07.018

13. Larsen BI, Skretting P, Farstad T. Hallway patients--consequences or the quality of care and patient integrity. Article in Norwegian. Tidsskr Nor Laegeforen.2000;120(22):2636-2638.

14. Lim C, Cheung MC, Trudeau ME, Imrie K, DeMendonca B, Singh S. The association between the transfer of emergency department admitted patients to inpatient hallways and outcomes of oncology patients. Journal of J Hosp Adm.2015;4(2):1-8.

15. Boudi Z, Lauque D, Alsabri M, et al. Association between boarding in the emergency department and in-hospital mortality: a systematic review. PLoS One. 2020;15(4):e0231253. doi:10.1371/journal.pone.0231253