Hospital leaders are familiar with emergency department boarding, but a different capacity challenge is growing in EDs as more people arrive needing not medical care, but a safe place to stay.
Although not a new issue, these so-called social holds are increasing in frequency and duration, hospital and health system leaders told Becker’s.
Baltimore-based LifeBridge Health defines social holds as patients who are medically cleared but do not have a safe location to be discharged, according to Amanda Shrout, DNP, RN, chief nursing officer and vice president of patient care services at LifeBridge Health’s Sinai Hospital and Grace Medical Center.
The health system began tracking social holds after a surge of them this summer. In the most recent fiscal year, July 1, 2024, through June 30, 2025, LifeBridge counted 20 holds on patients who did not have a safe discharge plan and were in the ED longer than seven days.
Since May, the health system has recorded two additional social holds. As of July 22, both have been lodged there for more than 30 days.
ED length of stay averages between two to six hours at LifeBridge, Dr. Shrout said, “but patients should never be staying in emergency departments greater than seven days, ever, in any situation.”
Becker’s heard similar stories from other health system leaders, including Paula Correa, DNP, RN, chief nursing officer of Atrium Health Wake Forest Baptist—High Point (N.C.) Medical Center, and Peggy Norton-Rosko, DNP, RN, senior vice president and system chief nurse executive of Baltimore-based University of Maryland Medical System.
According to the North Carolina Healthcare Association, 23% of adults and 13% of children who arrived at a North Carolina emergency department in 2024 for a behavioral health concern required hospitalization, indicating the majority did not and could receive treatment in the community.
Children are one of several communities that face risk of social holds. At LifeBridge, police, family members and guardians are bringing children to EDs not because they need emergency care but because they have no other options, Dr. Shrout said.
After ruling out any emergency or inpatient care needs, LifeBridge hospital staff then call Child Protective Services or Maryland’s department of human services, depending on the case. Every Monday, Wednesday and Friday, LifeBridge’s care management team and ED social workers meet to work on each case with a social hold.
The problem often lies in where the child should, or even can, go. Extensive backlogs at child welfare services and underinvestments in social services are contributing to this growing problem, according to healthcare industry experts.
The term “social hold” can encompass several situations, including patients who receive medical care and lack a safe discharge location, and those who only need a safe place.
“A good example of this is a recent patient who arrived, both parents were detained in other ways and he was found home alone,” Dr. Shrout said. “There was no medical concern for this patient, but he was a minor [who] arrived and, at that point, was then placed in our care without needing any medical treatment.”
Some health systems hire one-to-one sitters for these children to keep them occupied, but overall, emergency departments are not equipped to handle them.
Being stuck in a pediatric ED bed for days, weeks or even months can be dangerous. In the last year, 30% of workplace violence incidents in LifeBridge emergency departments involved pediatric patients. Most of those instances were among five patients staying in the ED longer than necessary, according to Dr. Shrout.
A study led by Rochester, Minn.-based Mayo Clinic found that, in 2022 and 2023, younger patients were much more likely to exhibit violence in the ED (24.5%) compared to other age groups, including patients older than 65 (3.7%). Healthcare facilities across the U.S. are reporting a rise in incivility.
In addition to the safety concerns, for hospitals, social holds disrupt patient flow and operational workflows, strain resources, and can cause a chain reaction of delayed care for incoming patients.
With respiratory virus season starting soon, “we worry about having these long stay kiddos in our emergency department when we have patients arriving who need medical care,” Dr. Shrout said.
Peter Pronovost, MD, PhD, chief quality and clinical transformation officer of Cleveland-based University Hospitals, said pediatric social holds often involve children with behavioral and mental health issues, including autism and anxiety.
“You think about the worst condition — it’s loud, it’s chaotic, it’s noisy, there’s people moving all around — for a frightened child, it’s probably the worst place you could think,” he said. “For someone who has some behavioral health issue, if you wanted a place that’s going to trigger somebody, the emergency department would be it.”
LifeBridge has child life specialists create daily schedules and activities for pediatric social holds, but at the end of the day, living in an ED exam room, surrounded by 24/7 bright lights and emergency medical scenes, is not an appropriate environment for children not needing inpatient care.
“We’ve gone to great lengths to make sure that they have things to do,” Dr. Shrout said, “and it’s not enough, because it’s not a home environment, it’s an emergency department.”
“When you think about the day-to-day life of a minor in a regular situation, it is night and day different [from] what they’re getting in an emergency department,” Dr. Shrout added. “They’re not getting any caregiving. And I think that’s the piece to this. We are not inherently parents or guardians of these children. We are healthcare workers who are trying to make sure that they are safe, first and foremost, and that everybody around them is safe.”
