Logo image
Back
National Trends in Emergency Department Boarding and Interfacility Transfers by Rurality
Journal article   Open access   Peer reviewed

National Trends in Emergency Department Boarding and Interfacility Transfers by Rurality

Elizabeth S Bermudez, Aidan Mullen, Nicholas M Mohr and Molly Jeffery
The Journal of rural health, Vol.42(4), e70222
09/2026
DOI: 10.1111/jrh.70222
PMID: 42788596
url
https://doi.org/10.1111/jrh.70222View
Published (Version of record) Open Access

Abstract

Emergency department (ED) boarding negatively impacts patient care nationwide. Rural hospitals are uniquely challenged as ED volumes increase despite declining inpatient capacity. Interfacility transfers are a growing component of rural ED operations and remain underexamined in evaluation of ED boarding. This study assessed trends in ED boarding and interfacility transfers by rurality. We conducted a repeated cross-sectional analysis using National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2001 to 2022 and a health system from 2019 to 2025. Outcomes included (1) yearly ED boarding proportions stratified by disposition and rurality and (2) yearly interfacility transfer proportions by rurality. We defined rurality using Metropolitan Statistical Area and Rural-Urban Commuting Area codes. Results were further stratified by medical and behavioral health patients. National ED boarding increased from 5.1% in 2001 to 11.3% in 2022, significant in urban (annual percentage change [APC] 5.3%, 95% CI 3.8%-6.8%) and rural (APC 9.1%, 5.1%-13.1%) hospitals. Health system ED boarding increased from 4.1% in 2019 to 10.8% in 2025, significant in urban (APC 13.6%, 7.1%-20.6%) and rural (APC 31.2%, 16.3%-48.1%) hospitals. ED boarding was highest for behavioral health transfers and increased significantly in rural health system hospitals. Health system medical transfer ED boarding increased faster in rural hospitals (p = 0.002), and annual medical transfer proportions were higher in rural EDs. ED boarding is increasing nationally. Rural transfer proportions exceed that of urban EDs and are an overlooked component of rural ED boarding. These findings have important policy implications with recent reimbursement changes and national boarding quality measures.
 United States Cross-Sectional Studies Emergency Room Visits Emergency Service, Hospital - organization & administration Emergency Service, Hospital - statistics & numerical data Emergency Service, Hospital - trends Health Care Surveys Hospitals, Rural - statistics & numerical data Humans Patient Transfer - statistics & numerical data Patient Transfer - trends Rural Population - statistics & numerical data

Details

Metrics

1 Record Views
Logo image