A study of 335 hospitals found a 20.3-minute gap in 2016 emergency department (ED) boarding measures between groups with lower and higher average medical-surgical nurse workloads, but could not establish cause and effect.
The study covered adult nonfederal acute-care hospitals in Florida, New Jersey and Pennsylvania. It classified hospitals with an average patient-to-nurse ratio below 5:1 as lower workload and those at or above 5:1 as higher workload. The 2016 annual mean boarding measure was 107.9 minutes for the lower-workload group and 128.2 minutes for the higher-workload group. The measure was the median time from an admission decision to an admitted patient’s departure from the ED, with the study comparing annual means of that measure.
Staffing data came from 1,367 medical-surgical nurses in the 2016 RN4CAST-US survey. Boarding data came from the Centers for Medicare & Medicaid Services’ (CMS) Hospital Compare Timely and Effective Care records for 2015 and 2016. Two adjusted analyses also found a gap of about 20 minutes in 2016: 19.2 minutes in a propensity-score-weighted analysis and 19.9 minutes in a doubly robust analysis.
The authors say the cross-sectional study cannot show that staffing levels caused the difference. Hospitals may have used different starting points for boarding timestamps, and the analysis did not establish whether unit bed limits affected hospitals’ staffing figures. The paper frames ED crowding as a demand and resource issue, with nursing as a possible way to improve patient flow, but does not estimate the cost or financial return of added staffing. It also cites proposed 4:1 medical-surgical nurse ratios in minimum-staffing legislation in New York and Pennsylvania.
Anna Valdez, editor of the Journal of Emergency Nursing, said in the Emergency Nurses Association’s Nov. 9 announcement that “Safe and appropriate staffing is critical to improving outcomes for emergency nurses and the communities they serve.” The paper appeared in the journal’s November 2026 issue and was published online July 29, 2026.
The study authors say CMS has discontinued public reporting of the boarding data and is revising measures through electronic clinical quality measures. Under CMS’ finalized schedule, reporting of the broader Emergency Care Access & Timeliness measure is voluntary for calendar year 2027 and mandatory beginning with calendar year 2028 for the calendar year 2030 payment determination. The measure includes ED boarding longer than four hours among several access and timeliness indicators.
