Emergency Department Boarding Time Is Associated with Functional Decline in Older Adults Six Months Post Discharge.

Functional decline following hospitalization remains an important problem in health care, especially for frail older adults. Modifiable factors related to reduction in harms of hospitalization are not well described. One particularly pervasive factor is emergency department (ED) boarding time; time waiting from decision to admit, until transfer to an in-patient medical unit. We sought to investigate how the functional status of frail older adults correlated with the length of time spent boarded in the ED. We found that patients who waited for 24 hours or more exhibited functional decline in both the Barthel Index and Hierarchical Assessment of Balance and Mobility and an increase in the Clinical Frailty Scale from discharge to 6 months post discharge. In conclusion, there is a need for additional investigation into ED focused interventions to reduce ED boarding time for this population or to improve access to specialized geriatric services within the ED.

Revisiting One of the Oldest Orphanages, Asylums, and Indigenous Residential Boarding Schools: The Thomas Indian School at Seneca Nation.

For Indigenous populations, one of the most recognized acts of historical trauma has come from boarding schools. These institutions were established by federal and state governments to forcibly assimilate Indigenous children into foreign cultures through spiritual, physical, and sexual abuse and through the destruction of critical connections to land, family, and tribal community. This literature review focuses on the impact of one of the oldest orphanages, asylums, and Indigenous residential boarding schools in the United States. The paper shares perspectives on national and international parallels of residential schools, land, truth and reconciliation, social justice, and the reconnection of resiliency-based Indigenous Knowledge towards ancestral strength, reclamation, survivorship, and cultural continuance.

The Child Welfare System's Response to the National Mental Health Crisis.

The nation's child welfare system serves the most vulnerable youth and families and so has been impacted dramatically by the coronavirus disease 2019 pandemic with decreases of abuse reporting, delayed toward permanency, and increased disproportionality. Youth in foster care have increased likelihood of boarding in hospital emergency rooms or nontraditional placements. These issues are magnified in exceptional vulnerable populations such as American Indian and Alaska Native children. The child welfare response to the national mental health crisis offers opportunities to redress chronic gaps and vulnerabilities within the systems of care serving these youth.

Addressing the Multidimensional Aspects of Trauma in Emergency Department Boarding for Neurodiverse Youth.

Psychiatric boarding in pediatric emergency departments is a predictable outcome of escalating psychiatric acuity and inadequate mental health services in hospital systems and the community at large. Guidelines are offered to support initiating treatments in nonpsychiatric hospital settings to reduce pediatric boarding. Treatments call for interdisciplinary approaches, care coordination, and addressing systemic disparities in access and quality of care. Telemental health interventions offer a promising means of reducing inequalities in access. Creating a crisis continuum of care will help minimize strict reliance on inpatient settings, which are increasingly challenging to access and only sometimes fully address the crises, even when used.

Does initiating care in alternate care sites decrease time to disposition in the emergency department?

Objectives: During the coronavirus disease 2019 (COVID-19) pandemic surge, alternate care sites (ACS) such as the waiting room or hospital lobby were created amongst hospitals nationwide to help alleviate emergency department (ED) overflow. Despite the end of the pandemic surge, many of these ACS remain functional given the burden of prolonged ED wait times, with providers now utilizing the waiting room or ACS to initiate care. Therefore, the objective of this study is to evaluate if initiating patient care in ACS helps to decrease time to disposition. Methods: Retrospective data were collected on 61,869 patient encounters presenting to an academic medical center ED. Patients with an emergency severity index (ESI) of 1 were excluded. The "pre-ACS" or control data consisted of 38,625 patient encounters from September 30, 2018 to October 1, 2019, prior to the development of ACS, in which the patient was seen by a physician after they were brought to an assigned ED room. The "post-ACS" study cohort consisted of 23,244 patient encounters from September 30, 2022 to October 1, 2023, after the initiation of ACS, during which patients were initially seen by a provider in an ACS. ACS at this institution included the three following areas: waiting room, ambulance waiting area, and a newly constructed ACS that was built next to the ED entrance on the first floor of the hospital. The newly constructed ACS consisted of 16 care spaces each containing an upright exam chair with dividers between each care space. Door-to-disposition time (DTD) was calculated by identifying the time when the patient entered the ED and the time when disposition was decided (admission requested or patient discharged). Using regression analysis, we compared the two data sets to determine significant differences among DTD time. Results: The largest proportion of encounters were among ESI 3 patients, that is, 56.1%. There was a significant increase in median DTD for ESI 2 and 3 patients who were seen initially in an ACS compared to those who were not seen until they were in an assigned ER room. Specifically, there was a median increase of 40.9 min for ESI 2 patients and 18.8 min for ESI 3 patients who were seen initially in an ACS (p < 0.001). There was a 29-min decrease in median DTD for ESI 5 patients who were seen in ACS (p = 0.09). Conclusions: Initiating patient care earlier in ACS did not appear to decrease DTD time for patients in the ED. Overall, the benefits of early initiation of care likely lie elsewhere within patient care and the ED throughput process.

The impact of emergency department crowding and patient boarding on resident point-of-care ultrasound education.

Objectives: Emergency department (ED) crowding negatively affects patient care, but the effect on resident education has been difficult to quantify. We aimed to describe the relationship between ED crowding and residents' ability to meet point-of-care ultrasound (POCUS) education goals. Methods: We retrospectively reviewed medical records from November 2021 to June 2023 at an academic level 1 trauma center, where emergency medicine residents complete longitudinal POCUS scanning shifts throughout 3 years of training. Residents are expected to complete ≥14 scans per scanning shift. We assessed whether completing the goal POCUS scans on a scanning shift (success: ≥14 scans, near-success: 10‒13, failure: <10) was associated with the average National Emergency Department Overcrowding Scale (NEDOCS) score or patient boarding hours during each scanning shift. Ordinal logistic regression was performed, controlling for the type of POCUS device available and the presence of medical students, interns, ultrasound faculty, and multiple residents. Results: Over 125 scanning shifts, 1340 scans were performed. Residents met the expected number of POCUS scans for 26.4% of scanning shifts, with 34.4% near-success and 39.2% failure. The average NEDOCS was 157.4 ± 31.9. POCUS success was associated with a lower mean NEDOCS (142 vs. 169, p < 0.001). After controlling for covariates, every 10-point increase in NEDOCS was associated with 17% lower odds of achieving the goal (odds ratio [OR] = 0.83, 95% confidence interval [CI] 0.73‒0.94, p = 0.003). Other significant factors were having only one resident on a scanning shift, which was associated with lower odds of success (OR = 0.41, 95% CI 0.18‒0.97, p = 0.043), and having a cart-based POCUS device available in addition to a handheld POCUS device, which was associated with higher odds of success (OR = 13.58, 95% CI 5.53‒33.38, p < 0.001). Conclusion: As ED crowding increased, residents were increasingly likely to fail to meet their POCUS education goals.

Impact of emergency department boarding on patients outcomes in hip fractures.

BACKGROUND: Boarding time in the Emergency Department (ED) is an area of concern for all patients and potentially more problematic for the hip fracture population. Identifying patient outcomes impacted by ED boarding and improving emergent care to reduce surgical delay for this patient population is a recognized opportunity. The objective of this study is to examine the impact of ED boarding in relation to patient outcomes in the surgical hip fracture population. METHODS: This is a retrospective study of hip fracture patients who presented at the ED of a Level 1 trauma center between January 2020 and December 2021. Patients were categorized into four quartiles based on boarding time. Study outcomes-hospital length of stay, time to surgery, visit to ICU post-operative, total blood products, in-hospital complications, discharge disposition, in-hospital mortality, and 30-day readmission-were compared among these four quartiles. RESULTS: The outcome endpoints were comparable among the four quartiles except for time to surgery. Time to surgery significantly differed among the quartiles, increasing from 20.39 to 29.03 h (p < 0.001) from the first to fourth quartile. CONCLUSION: In contrast to the existing literature, ED boarding in our study was not associated with adverse outcomes except for time to surgery. By expediting the time to surgery in accordance with established guidelines, adverse outcomes were mitigated even when our patients boarded for a longer duration. System processes including a 24/7 trauma nurse practitioner model, availability of in-house orthopedic surgeons, and timely cardiac evaluation need to be considered in relation to time to surgery, in turn impacting ED boarding and patient outcomes.

Effect of access block on emergency department crowding calculated by NEDOCS score.

OBJECTIVE: Emergency department (ED) crowding poses a significant challenge in healthcare systems globally, leading to delays in patient care and threatening public health and staff well-being. Access block, characterized by delays in admitting patients awaiting hospitalization, is a primary contributor to ED overcrowding. To address this issue, the National Emergency Department Overcrowding Study (NEDOCS) score provides an objective framework for assessing ED crowding severity. This study aims to evaluate the impact of access block on ED crowding using the NEDOCS score and to explore strategies for mitigating overcrowding through scenarios over a 39-day period. METHODS: A single-center, prospective, observational study was conducted in an urban tertiary care referral center. The NEDOCS score was collected six times daily, including variables like total ED patients, ventilated patients, boarding patients, the longest waiting times, and durations of boarding patients. NEDOCS scores were recorded, and calculations were performed to assess the potential impact of eliminating access block in scenarios. RESULTS: NEDOCS scores ranged from 62.4 to 315, with a mean of 146, indicating consistent overcrowding. Analysis categorized ED conditions into different levels, revealing that over 81.2% of the time, the ED was at least overcrowded. The longest boarding patient's waiting duration was identified as the primary contributor to NEDOCS (48.8%). Scenarios demonstrated a significant decrease in NEDOCS when access block was eliminated through timely admissions. Shorter boarding times during non-working hours suggest the potential mitigating effect of external factors on the access barrier. Additionally, daytime measurements were associated with lower patient admissions and shorter wait times for initial assessment. CONCLUSION: Although ED crowding is a multifactorial problem, our study has shown that access block contribute significantly to this problem. The study emphasizes that eliminating access block through timely admissions could substantially alleviate crowding, highlighting the importance of addressing this issue to enhance ED efficiency and overall healthcare delivery.

Emergency nurses' perspectives on mental health boarders: An integrative review.

This integrative review is on emergency department nurses' perceptions on mental health patients waiting for placement. Seven articles met inclusion criteria. Themes included violence and patient safety, psychiatry and mental health support, attitudes and beliefs, education and training, emergency department workflow and environment, and long waits in the emergency department. Future research focusing on the care of mental health patients boarding in the emergency department is needed to address this issue. A limitation was that there were no focused studies on mental health boarders in the emergency department, and information had to be gleaned from articles on caring for mental health patients in emergency departments in general.

Pearls for Caring for the Boarding Psychiatric Patient in the Emergency Department.

BACKGROUND: Emergency department (ED) boarding of psychiatric patients is a national issue that continues to worsen at a disturbing rate. Implementing strategies in the ED to provide continuous care for patients can help secure patient safety. OBJECTIVE: The objective of this review is to discuss the boarding of psychiatric patients and its implications. It will focus on executing best clinical practices in managing boarding psychiatric patients in the ED. It will not focus on the treatment of substance use disorders. DISCUSSION: This article will address the pearls for management plans that can be implemented in the ED, alongside discussing pregnant and elderly patients. Risk factors, complications, and treatments for boarding psychiatric patients are discussed. CONCLUSIONS: Patients with psychiatric disorders boarding in the ED need careful consideration of management plans to mitigate patient safety events.

An Analysis of New York Data: Fluctuations in Hospital Capacity Are Driven by Variability in Elective Admissions and Discharge Activity.

Background Hospital overcrowding compromises patient safety. The contribution of variability in admissions and discharges to overall hospital capacity needs to be quantified. This study describes the statewide day-to-day fluctuation in the volume of hospitalized patients, the variability and pattern of hospital admissions and discharges throughout the week, and the contribution of Emergency Department (ED) vs. elective (non-ED) admissions and discharges to the overall variability in the system across the week. Methodology This is a retrospective analysis of the New York State Statewide Planning and Research Cooperative System database, in which all New York healthcare facilities submit patient-level data monthly. The study period was from January 01 to December 31, 2015. Outcomes included total volumes of admissions and discharges and length of stay sorted by patient origin (ED vs. non-ED admits (elective)) and service type (medicine vs. surgery) by day of the week. Results We studied 1,692,090 hospital admissions. Admissions were highest on Mondays and Tuesdays and steadily decreased throughout the week. There was little variability in the ED admissions throughout the week. Surgical elective admissions had significant variability throughout the week, with higher admissions at the beginning of the week. There was a significant difference (p < 0.01) between admissions on weekdays vs. weekends. Discharges increased from Monday to Friday, with a dramatic drop on the weekends, for both ED and elective pathways. Systemwide, on Monday, hospitals were 21% above the mean volume, and on Fridays, hospitals were 32% below the mean volume. Conclusions Overall hospital capacity shows dramatic variability throughout the week, driven primarily by elective admissions and discharges from any source throughout the week. Because elective admissions are schedulable, hospitals can reduce variability by smoothing scheduling. Increased weekend discharges will also improve capacity.

The impact of boarding school on student development in primary and secondary schools: a meta-analysis.

As a long-established model of schooling, the boarding system is commonly practiced in countries around the world. Numerous scholars have conducted a great deal of research on the relationship between the boarding school and student development, but the results of the research are quite divergent. In order to clarify the real effects of boarding school on students' development, this study used meta-analysis to quantify 49 (91 effect sizes) experimental or quasi-experimental studies on related topics at home and abroad. The results find that: (1) Overall, boarding school has no significant predictive effect on student development, with a combined effect size of 0.002 (p > 0.05); (2) Specifically, boarding school has a significant positive predictive effect on students' cognitive development (g = 0.248, p < 0.001), a significant negative predictive effect on students' affective and attitudinal development (g = -0.159, p < 0.05), and no significant predictive effect on students' behavioral development (g = -0.115, p > 0.05) and physical development (g = -0.038, p > 0.05); (3) The relationship between the two is moderated by the school stage and the type of boarding school, but not by the instruments; (4) Compared with primary school students, senior high school students and urban boarding students, the negative predictive effect of boarding system on junior middle school students and rural boarding students is more significant. In addition, there are some limitations in the study, such as the limited number of moderator variables included, the results of the study are easily affected by the quality of the included literature, and the dimensionality of the core variable "student development" is not comprehensive enough. In the future, further validation should be conducted through in-depth longitudinal or experimental studies.

Association between Boarding of Frail Individuals in the Emergency Department and Mortality: A Systematic Review.

(1) Background: Older patients who attend emergency departments are frailer than younger patients and are at a high risk of adverse outcomes; (2) Methods: To conduct this systematic review, we adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. We systematically searched literature from PubMed, Embase, OVID Medline®, Scopus, CINAHL via EBSCOHost, and the Cochrane Library up to May 2023, while for grey literature we used Google Scholar. No time restrictions were applied, and only articles published in English were included. Two independent reviewers assessed the eligibility of the studies and extracted relevant data from the articles that met our predefined inclusion criteria. The Critical Appraisal Skills Program (CASP) was used to assess the quality of the studies; (3) Results: Evidence indicates that prolonged boarding of frail individuals in crowded emergency departments (Eds) is associated with adverse outcomes, exacerbation of pre-existing conditions, and increased mortality risk; (4) Conclusions: Our results suggest that frail individuals are at risk of longer ED stays and higher mortality rates. However, the association between the mortality of frail patients and the amount of time a patient spends in exposure to the ED environment has not been fully explored. Further studies are needed to confirm this hypothesis.

Reducing Pediatric Mental Health Boarding and Increasing Acute Care Access.

BACKGROUND: There have been notable increases in pediatric mental health boarding in the United States in recent years, with youth remaining in emergency departments or admitted to inpatient medical/surgical units, awaiting placement in psychiatric treatment programs. OBJECTIVES: We aimed to evaluate the outcomes of interventions to reduce boarding and improve access to acute psychiatric services at a large tertiary pediatric hospital during a national pediatric mental health crisis. METHODS: Boarding interventions included expanding inpatient psychiatric beds and hiring additional staff for enhanced crisis stabilization services and treatment initiation in the emergency department and on inpatient medical/surgical units for boarding patients awaiting placement. Post-hoc assessment was conducted via retrospective review of patients presenting with mental health emergencies during the beginning of intervention implementation in October-December 2021 and one year later (October-December 2022). Inclusion criteria were patients ≤17 years who presented with mental health-related emergencies during the study period. Exclusion criteria were patients ≥18 years and/or patients with >100 days of admission awaiting long-term placement. Primary outcome was mean length of boarding (LOB). Secondary outcome was mean length of stay (LOS) at the hospital's acute psychiatry units. RESULTS: One year after full intervention implementation (October-December 2022), mean LOB decreased by 53% (4.3 vs 9.1 days, P < 0.0001) for boarding patients discharged to high (e.g., inpatient, acute residential) and intermediate (e.g., partial hospital, in-home crisis stabilization programs) levels of care, compared to October-December 2021. Additionally, mean LOS at all the 24-hour acute psychiatry treatment programs was reduced by 27% (20.0 vs 14.6 days, P = 0.0002), and more patients were able to access such programs (265/54.2% vs 221/41.9%, P < 0.0001). Across both years, youth with aggressive behaviors had 193% longer LOB (2.93 ± 1.15, 95% CI [2.23, 3.87]) than those without aggression, and youth with previous psychiatric admissions had 88% longer LOB than those without (1.88 ± 1.11, 95% CI [1.54, 2.30]). CONCLUSIONS: The current study shows decreased LOB and improved access for youth requiring acute psychiatric treatment after comprehensive interventions and highlights challenges with placement for youth with aggressive behaviors. We recommend a call-to-action for pediatric hospitals to commit sufficient investment in acute psychiatric resources to address pediatric mental health boarding.

Increasing and sustaining discharges by noon - a multi-year process improvement project.

High hospital occupancy degrades emergency department performance by increasing wait times, decreasing patient satisfaction, and increasing patient morbidity and mortality. Late discharges contribute to high hospital occupancy by increasing emergency department (ED) patient length of stay (LOS). We share our experience with increasing and sustaining early discharges at a 650-bed academic medical center in the United States. Our process improvement project followed the Institute of Medicine Model for Improvement of successive Plan‒Do‒Study‒Act cycles. We implemented multiple iterative interventions over 41 months. As a result, the proportion of discharge orders before 10 am increased from 8.7% at baseline to 22.2% (p < 0.001), and the proportion of discharges by noon (DBN) increased from 9.5% to 26.8% (p < 0.001). There was no increase in balancing metrics because of our interventions. RA-LOS (Risk Adjusted Length Of Stay) decreased from 1.16 to 1.09 (p = 0.01), RA-Mortality decreased from 0.65 to 0.61 (p = 0.62) and RA-Readmissions decreased from 0.92 to 0.74 (p < 0.001). Our study provides a roadmap to large academic facilities to increase and sustain the proportion of patients discharged by noon without negatively impacting LOS, 30-day readmissions, and mortality. Continuous performance evaluation, adaptability to changing resources, multidisciplinary engagement, and institutional buy-in were crucial drivers of our success.

Spatial and emotional distances in parent-child relationships: Impacts on human capital development in rural Chinese boarding children.

BACKGROUND: The policy of merging remote rural elementary schools into centralized villages has led to the emergence of boarding schools as an essential means of providing compulsory education in rural areas of China. As boarding children reside in schools for extended periods, parents' influence on their human capital development is inevitably specificity. The development of rural boarding children is a serious social issue in China, and parent-child distance plays a crucial role in affecting the development of children's human capital. OBJECTIVE: While previous studies have focused on the relationship between parental absence and the development of human capital in rural boarding children, this study examines the effects of both spatial and emotional distance between parents and children on the human capital of rural boarding children. PARTICIPANTS AND SETTING: A stratified, multi-stage probabilities proportional to size (PPS) sampling method was used, and self-report questionnaires were completed by 2397 rural boarding children (54.2 % males; ages 12 to 18, M = 14.66, SD = 1.30). METHODS: Children's background, family, and school and teacher characteristics were used as control variables. An OLS regression model was used to assess the effects of parent-child spatial and emotional distance on the human capital of rural boarding children, and a CMP-OLS regression model was used to address endogeneity using parents' self-assessed family economic conditions as instrumental variables. RESULTS: Parent-child spatial distance had a significant positive effect (p < 0.05, p < 0.05), and emotional distance had a significant negative effect (p < 0.05, p < 0.01) on the cognitive and non-cognitive abilities development of rural boarding children. Living with grandparents heightened the negative effect on non-cognitive abilities development. CONCLUSIONS: The findings of this study strengthen the link between parent-child distance and rural boarding children and the moderating impact of living with grandparents on the effect of parent-child distance on rural boarding children's human capital providing new insights for promoting the development of rural boarding children. It also highlights the detrimental effects of emotional neglect on rural boarding children's development. This is important for realizing China's rural revitalization strategy and the healthy development of disadvantaged children in rural areas.

Price for waiting: the adverse outcomes of boarding critically ill elderly medical patients in the emergency department.

PURPOSE: Boarding, the period in which a patient spends in the emergency department (ED) before admission, may be hazardous to critically ill patients, particularly the elderly. This study investigated the associations of boarding with hospital course, prognosis, and medical expenditure in older patients. METHODS: From January 2019 to December 2021, the medical records of older patients (age ≥ 65) visiting the ED of a tertiary referral hospital who were admitted to the medical intensive care unit (ICU) were retrospectively reviewed. Eligible patients were categorized into two groups according to boarding time with a cutoff set at 6 h. Primary outcomes were in-hospital mortality, ICU/hospital length of stay, and total/average hospitalization cost. Subgroup analyses considered age and disease type. RESULTS: Among 1318 ICU admissions from the ED, 36% were subjected to boarding for over 6 h. Prolonged boarding had a longer ICU (8.9 ± 8.8 vs. 11.2 ± 12.2 days, P < .001) and hospital (17.8 ± 20.1 vs. 22.8 ± 23.0 days, P < .001) stay, higher treatment cost (10.4 ± 13.9 vs. 13.2 ± 16.5 thousands of USD, P = .001), and hospital mortality (19% vs. 25% P = .020). Multivariate regression analysis showed a longer ICU stay in patients aged 65-79 (8.3 ± 8.4 vs. 11.8 ± 14.2 days, P < .001) and cardiology patients (6.9 ± 8.4 vs. 8.8 ± 9.7 days, P = .001). Besides, the treatment cost was also higher for both groups (10.4 ± 14.6 vs. 13.7 ± 17.7 thousands of USD, P = .004 and 8.4 ± 14.0 vs. 11.7 ± 16.6 thousands of USD, P < .001, respectively). CONCLUSION: Extended ED boarding for critically ill medical patients over 65 years old was associated with negative outcomes, including longer ICU/hospital stays, higher treatment costs, and hospital mortality.

Gaps and Opportunities for Strengthening In-School Support for Youth Living With HIV.

OBJECTIVES: With optimized antiretroviral treatment youth living with HIV (YLH) now spend most of their time in schools, making schools an important venue to optimize outcomes. We evaluated school support for YLH. METHODS: We conducted surveys with public secondary/high schools in 3 Kenyan counties (Nairobi, Homa Bay, and Kajiado) to determine policies and training related to HIV. Chi-squared tests and Poisson regression were used to compare policy availability and staff training by county HIV prevalence and school type. RESULTS: Of 512 schools in the 3 counties, we surveyed 100. The majority (60%) of schools surveyed had boarding facilities. The median student population was 406 (IQR: 200, 775). Only half (49%) of schools had medication use policies; more in boarding than day schools (65% vs 30%, p = .003). While most schools (82%) had clinic attendance policies; policy availability was higher in higher HIV prevalence counties (Homa Bay [100%], Nairobi [82%], Kajiado [56%], p < .05). Overall, 64% had confidentiality policies with higher policy availability in higher HIV prevalence regions (p < .05). Few schools had staff trained in HIV-related topics: HIV prevention (37%), HIV treatment (18%), HIV stigma reduction (36%). Few were trained in confidentiality (41%), psychosocial support (40%), or mental health (26%). Compared to day schools, boarding school were more likely to have staff trained in HIV prevention (prevalence ratio: 2.1 [95% confidence interval 1.0, 4.0], p = .037). CONCLUSION: In this survey of Kenyan schools, there were notable gaps in HIV care policy availability and training, despite high HIV burden. Development and implementation of national school HIV policies and staff training as well as strengthening clinic and family support may improve outcomes for YLH.

Characteristics and patient impact of boarding in the pediatric emergency department, 2018-2022.

OBJECTIVES: Boarding admitted patients in the emergency department is an important cause of throughput delays and safety risks in adults, though has been less studied in children. We assessed changes in boarding in a pediatric ED (PED) from 2018 to 2022 and modeled associations between boarding and select quality metrics. METHODS: We performed a retrospective analysis of PED patients admitted to non-psychiatric services, broken into four periods: pre-COVID-19 (Period I, 01/2018-02/2020), early pandemic (II, 03/2020-06/2021), COVID-19 variants (III, 07/2021-06/2022), and non-COVID respiratory viruses (IV, 07/2022-12/2022). Patients were classified as critical (intensive care units (ICU)) or acute care (non-ICU inpatient services) based on their initial bed request. We compared median boarding times with Kruskal-Wallis tests. We assessed the relationship between boarding time and hospital length-of-stay (LOS) through hazard regression models, and the association between boarding time and PED return visit, readmission, and patient safety events through adjusted logistic regressions. RESULTS: Median PED boarding time significantly increased from Period I (acute: 2.4 h; critical: 3.0 h) to Period II (acute: 3.0 h, critical: 4.0 h) to Period III (acute: 4.4 h, critical: 6.6 h) to Period IV (acute: 6.2 h; critical: 9.5 h). On survival analysis, as boarding time increased, hospital LOS increased for acute admissions and decreased for critical admissions. Increased acute care boarding time was associated with higher odds of a filed safety report. CONCLUSIONS: Since July 2021, PED boarding time increased for admitted children across acute and critical admissions. The relationship between acute care boarding and longer hospital LOS suggests a resource-inefficient, self-perpetuating cycle that demands multi-disciplinary solutions.