Key Dates

Related Announcements

None

Issued by

AGENCY FOR HEALTHCARE RESEARCH & QUALITY (AHRQ)

Purpose

The purpose of this Special Emphasis Notice (SEN) is to inform the research community of the Agency for Healthcare Research and Quality’s (AHRQ) strong and continued interest in receiving health services research grant applications for addressing Emergency Department (ED) boarding and hospital crowding. We seek system-wide innovations to reduce or eliminate crowding and boarding so patients receive timely, condition-appropriate care without adverse events from delayed, omitted, harmful, or distracted care. We also seek research that addresses challenges and proposes care solutions that comply with Emergency Medical Treatment and Labor Act (EMTALA) obligations, deliver effective and efficient system-wide Emergency Medical Services (EMS), and reduce diagnostic error, staff burnout, and turnover in ED and emergency care settings.

Approximately 140 million visits are made to EDs annually in the United States. This volume reflects a significant demand on healthcare systems. ED boarding, the practice of holding or physically keeping patients in the ED after admission (usually due to a lack of staffed beds in the hospital, hospitals operating over their capacity, or inability to transfer patients elsewhere for appropriate care), is again at critical levels in U.S. healthcare systems and globally. Reduction in available inpatient beds, hospital staffing shortages, mismatched payment systems, and increased patient volume and complexity, among other issues, have resulted in patients waiting for days in crowded EDs. ED boarding causes various issues, including patient harm, and is linked to higher mortality rates, increased medical errors, longer hospital stays, increased healthcare costs, staff burnout, ED violence, and strain that ripples through entire healthcare systems in communities. Children, older adults, those with multiple chronic conditions, those with Medicaid or uninsured, those with acute behavioral health emergencies, and racial and ethnic minorities are disproportionately impacted, leading to significantly worse health disparities.

This SEN conveys AHRQ’s interest in supporting health services research that will focus on questions related to the development, implementation, and evaluation of activities to reduce ED boarding by addressing the lack of adequate resources to care for patients presenting to the ED in need of inpatient care or transfer for further stabilization or specialized services, improving patient safety and ultimately quality of care. This SEN builds on AHRQ’s prior work, including extramurally funded research. It also supports AHRQ’s ongoing commitment to including priority populations in health services research (About Priority Populations | Agency for Healthcare Research and Quality (ahrq.gov).

We consider research that seeks to address systems-level change. AHRQ encourages applications that focus on a variety of research areas, including, but not limited to, the following categories and topics:

System-wide financial and Regulatory Pressures and Enhancements

• Research examining how healthcare systems' political-economic structures, financing, or organization impact emergency services utilization and health outcomes, particularly for systems that serve populations with health disparities.
• Research that engages with government, industry, health system C-Suite leadership, and other responsible parties to understand cultural, financial, and regulatory barriers and solutions to ED boarding and the prioritized care of ED patients.
• Research on local, state, or national policies, including incentives, structural/process requirements, quality measures, or other practices that affect the capacity to meet patients’ needs to avoid ED boarding, particularly among patients with complex medical and social needs.
• Research to examine the assumptions of traditional hospital cost accounting methods that may distort actual direct and indirect costs of boarding and research to develop or apply more sophisticated techniques of cost accounting implementable by a diverse array of hospitals, including those with minimal resources, to assess costs of boarding more directly and accurately.
• Research examining differences in resource use, care intensity, care coordination, re-evaluation frequency, clinician cognitive services, and other clinical services provided to boarding patients, compared to similar patients in traditional hospital inpatient settings.
• Research that examines the impacts and costs of a “bundle” or “portfolio” of hospital tactics to manage hospital throughput and capacity actively and embed support in EDs to provide best-in-class, patient-friendly ED experiences.

Addressing Downstream, Upstream, and Throughput Needs

• Exploration or demonstration of successful healthcare delivery models that reduce the burden on inpatient services, including care coordination and alternatives to hospital admission.
• Research that explores and evaluates methods that better match hospital capacity to demand, expand inpatient bed availability based on ED occupancy and need for inpatient services (with surge plans to accommodate predictable or unpredictable variation in demand), improve the efficient management of inpatient beds and services, and improve timely, efficient, and safe hospital discharges.
• Research to develop models for healthcare delivery (including pragmatic plans that assess financial costs and regulatory policies) that improve access to outpatient care, rehabilitation services, and social services and create options and incentives for efficient transfers from the ED and/or inpatient services for specialized needs (such as long-term care and acute behavioral health care).

Data Measurement and Tracking

• Novel approaches to observe, track, predict, and address hospital occupancy, census, boarding, capacity, or health system demand may not be intrinsic to EDs but may be relevant to ED boarding.
• Research examining how the internal socio-cultural context of EDs, hospitals, or health systems impacts data collection, measurement, and patient boarding.
• Enhancements and leveraging of technology, including healthcare information systems that provide real-time tracking to help hospitals, EDs, communities, and patients react to real-time information and make informed choices and decisions about load balancing and resource allocation.

Workforce Development and Solutions

• Research that examines or implements staffing solutions for short and long-term training, recruitment, hiring, and staff retention, including methods to increase the number of nurses, promote workforce satisfaction, and improve safety.
• Research on issues that impact or support workforce readiness and training, such as housing, loan payments, or higher education pathways, to promote the development and training of the workforce.
• Research that examines workforce policies addressing work hours, patient load, support services, and available family and sick leave to create a stable and healthy workforce.

Creation of Resources and Toolkits

• Research, develop, and test best practices and toolkits for different types of ED settings and healthcare systems (e.g., size, rurality, staffing, facilities).
• Research leading to the development of resources to improve workforce, patient, or family experiences in emergency departments.
• Research leading to the development of potential applications of artificial intelligence to evaluate, mitigate, and eliminate ED boarding.

Patient Experience and Other Special Conditions

• Research examining the patient perspective and experience of ED boarding, including the social, cultural, and economic toll of ED boarding on caregivers, families, and patients.
• Research addressing ED boarding by engaging with those with special conditions or populations, such as behavioral health conditions, substance use, children, the elderly, rural, unhoused populations, and people with disabilities.
• Research examining ED boarding in combination with other AHRQ Special Emphasis Notices.

The Agency encourages research teams to submit applications in response to this SEN using AHRQ’s current research grant announcements – See https://www.ahrq.gov/funding/fund-opps/index.html.

Specifically, the Agency encourages research teams to submit applications in response to this emphasis using AHRQ’s standing R18, R03, and R01 funding mechanisms (PA-24-156, PA-24-155, PA-24-154) or any reissue of these NOFOs through the expiration date of this SEN. AHRQ is also interested in receiving career development awards using AHRQ’s K01, K08, and K18 funding mechanisms (PA-22-255, PA-22-232, PA-22-051, PA-22-050, and PA-22-049) that propose developing generalizable health service research skills through projects related to research aging. Additionally, AHRQ is interested in receiving dissertation grant proposals addressing ED boarding and crowding health services research using AHRQ’s R36 funding mechanism (PA-23-196).

Applicants should clearly state in their grant application’s project summary/abstract that their application is responsive to this SEN by including the title and number of this SEN NOT-HS-25-012. Applicants should also enter the number of this SEN in box 4b (Agency Routing Identifier) of the SF 424 (R&R) Form.

Applications responding to this SEN should be submitted following regular application receipt dates identified in the respective NOFO and will be reviewed by AHRQ standing study sections.

Applicants should consider this SEN active until December 20, 2027.

Inquiries

Please direct all inquiries to:

Karen Cosby, MD

Agency for Healthcare Research and Quality

Email: [email protected] or [email protected]