Last night when I came to work most of the beds in our 31-bed emergency department (ED) were full. There were more than 20 patients either in the waiting room proper or in the chairs that serve as “rooms” behind the triage area.

Much of the problem was the fact that we were boarding patients who were waiting on inpatient beds, psychiatric admissions, or transfer to higher levels of care elsewhere. By 2 a.m., I was the sole physician, along with a nurse practitioner, responsible for a department with more than 20 patients, 10 of whom were holds, along with 17 in the waiting room.

Now, there are EDs busier than this, and there are always physicians seeing sicker patients somewhere else. Still, our acuity was high, including a critical patient who was intubated, receiving blood, vasopressors, sedation, and antibiotics. The stack of EKGs performed on patients with chest pain grew thicker through the night. And all I could think as I looked at our tracking board was, “This is just dangerous.”

Boarding is a problem across the country. It’s one of those frustrating, multifactorial issues that make modern EDs so miserable for professionals and patients alike. Research suggests that boarding is dangerous. Not only does it seem to increase mortality of elderly inpatients kept overnight, it also may increase agitation and delirium in the elderly. The issue has long been on the radar of The Joint Commission. In fact, The Joint Commission has seemingly suggested that ED boarding should be managed by boarding patients in hallway beds on the inpatient units. This, of course, is seldom met with enthusiasm by hospital management or nursing.

So, why is there so much boarding? The classic answer is that we have a nursing shortage, which manifests as a bed shortage, so hospitals have no place to put patients. We also have a shortage of nursing home and rehab beds and a surplus of people who need them. Therefore, patients who could be discharged aren’t. Also, hospitals keep beds open for post-surgery care, which makes sense, I suppose, because surgeries reimburse well.

All of those reasons are true—but I think there are other reasons too.

For one thing, there are transfers. In a time when we’re all afraid of litigation, conditions or ailments that might be admitted to community hospitals often are not, as physicians don’t feel comfortable stepping outside defined boundaries. These patients are typically transferred from the ED to other locales. Small-to-medium-sized hospitals also have to send people out due to limited specialty resources, insufficient ICU beds, inadequate quantities of blood products, or any number of reasons.

The crisis of mental illness and addiction also fills our beds. Psychiatric hospitalizations are often difficult to obtain, and the criteria for admitting them can be complex. It may have to do with insurance status, degree of aggression, medical comorbidities, or a patient’s prior history of being problematic (that is, “burned bridges”).

Patients brought or sent to the ED for nursing home placement also take up beds and can be in the ED for days to weeks, quite literally. While necessary, the beds they take up are not available for acute care; they simply turn high-speed, high-tech departments into warehouses, as the old and infirm await their own transfers to new living conditions.

Transfers can take anywhere from hours to days to accomplish as we wait for beds to open at the equally stressed referral centers. Then, once accepted, it can be an issue of transport. Ambulances and helicopters are not infinite resources. Patients may board simply because there’s literally no physical way to get them transferred. A family member at a rural hospital once asked me, “What do you mean there aren’t any ambulances?”

“I mean, ma’am, we just don’t have one available. Not until morning at least.” It’s a shocking thing to say and to hear.

Of course, the consequences of the boarding crisis go beyond frustration or even poor outcomes. The chaos of a crowded ED—where staff are watching both new patients and boarded patients—can cause other downstream effects. It is exhausting, it is overstimulating, and it is extremely anxiety-inducing. Subject a professional to enough of this, and they will absolutely find another job.

Furthermore, the attention and physical space required by boarded patients cause the new patients to wait longer in the waiting room. Privacy cannot be protected very well in chairs lined up in hallways or in fast-track rooms separated by curtains.

It’s difficult to do a thorough exam, obtain labs or X-rays, or give any therapies with insufficient nursing staff in triage areas or managing hallway patients. So, long-term boarded patients can, through no fault of their own, cause poorer care for the new and potentially very sick patients just beyond the entryway. It used to be somewhat axiomatic that if someone left before being seen, they just weren’t sick. That’s untrue. Very sick patients leave out of discomfort and exhaustion. No doubt, some of them die.

In addition, this year’s terrible flu season has led me to wonder if our boarding practices—our patients crammed in waiting rooms for hours, shoulder to shoulder—haven’t led to increased transmission of viral illnesses. Particularly at a time when primary care offices tend to refer so much to the ED for further evaluation.

The nurses and physicians, medics and techs, NPs and PAs I know don’t mind hard work—or supporting sick patients. What they mind is being overwhelmed daily and having fewer resources and less space in which to do their jobs.

One of the great frustrations we have in emergency medicine is that we feel abandoned by administrations, both locally and at large. At the end of the day, new solutions are rarely offered, and when 5 p.m. rolls around, the evening and night staff continue to do the best they can with more patients and ever-diminishing resources.

It seems that the very least our leaders could do would be to take seriously the issue of boarding. To use the parlance of recent years: the boarded, and those unable to be seen due to lack of beds, are all customers.

And we want happy customers, don’t we?

Edwin Leap is an emergency physician who writes at the Substack, Life and Limb, and is the author of the Practice Test and Life in Emergistan.