Emergency department overcrowding and boarding remain chronic challenges in U.S. hospitals. These issues strain staff, inflate costs and jeopardize patient outcomes. But the healthcare system’s flow challenges do not begin on the inpatient floor, they start at the front door. With hospitals facing rising ED boarding rates and capacity constraints, solving flow holistically requires upstream visibility and coordinated action across the entire patient journey.
As hospitals continue to face pressure to improve patient flow, a clear takeaway has emerged: ED boarding is not an ED problem alone. It is a systemic issue that demands a comprehensive operational strategy. Rather than focusing narrowly on ED metrics, successful organizations have improved performance by addressing hospital-wide inefficiencies, especially those at the end of the patient journey. By optimizing discharge processes, using alternative care pathways and deploying advanced technologies, they are creating sustainable reductions in ED boarding.
Here are four ways hospitals can reduce ED boarding and bring efficiency to their patient flow approaches.
Start with Home Discharges
A significant portion of hospital discharges—about 60%—are to home. These discharges represent the clearest opportunity to free up inpatient beds and alleviate ED pressure. Yet they are often delayed by fragmented communication, unclear discharge plans and operational silos.
Baptist Health Arkansas is tackling this issue head-on by connecting nursing, care management and logistics teams using real-time patient-level discharge predictions and streamlined huddle discussions around barrier resolution. Within a year, the health system reduced ED boarding by 35% and also experienced increases in early discharges, patient transfers and admissions, as well as a drop in diversion and left-without-treatment-complete rates.
Leverage Alternative Pathways
In addition to timely home discharges, ED throughput improves when patients are directed to their appropriate care setting and don't have to wait for care in a highly acute setting. This is essential for preserving inpatient capacity. When lower-acuity patients occupy high-acuity resources, it limits a hospital’s ability to care for those who truly need that level of care. Leading systems are addressing this by expanding access to short-stay units, hospital-at-home programs and community-based services. The key is early identification, flagging patients who are eligible for these alternatives and routing them to the right care setting before an inpatient bed is unnecessarily used. This ensures hospitals optimize both their capacity and the level of care they provide.
Sarasota Memorial Health Care System exemplifies this strategy in action. Through better utilization of alternative care programs and predictive technology, the organization achieved a 32% reduction in ED boarding hours and a 22% increase in ED visits, all while improving patient throughput and staff satisfaction.
Optimize Hospital-Wide Operations
Long-term success requires a systemic approach to operations. With robust AI-enabled tools, health systems can proactively plan discharges, ensure cross-departmental readiness and standardize discharge workflows. This includes the introduction of predictive and data-driven surge plans ensuring that emergency departments will not experience diversion. These plans make sure everyone—from the ED to the inpatient floors to the executive suite—all operate with the same awareness and mindset to ED capacity.
Using this holistic approach, Baptist Health Arkansas applied operational principles drawn from manufacturing to eliminate waste and prepare for discharges earlier in the day. Predictive analytics identified likely discharges the day prior, allowing for tasks such as medication reconciliation and transportation planning to be completed in advance. These efforts led to a 34% reduction in geometric mean length of stay variance and a 25% drop in opportunity days.
Sarasota Memorial saw similar gains, decreasing average length of stay by 13 hours and cutting discharge processing time by 10%. Notably, 40% of their discharge orders are now written by 1 p.m., reflecting a significant cultural shift toward earlier and more predictable discharges.
Anticipate, Don’t Just React
While discharge optimization relieves downstream pressure, today’s challenges demand a forward-looking approach to patient intake and flow from the moment of arrival. Health systems need tools that forecast surges in ED volume, identify emerging bottlenecks and escalate potential delays before they cascade.
By embedding predictive insights into ED operations, hospitals can dynamically manage bottlenecks, prioritize diagnostics and prepare inpatient teams—all based on what’s about to happen, not just what has already occurred. This kind of operational foresight transforms the ED from a reactive environment into a coordinated, intelligent entry point for the entire hospital.
ED boarding is inevitable, and every hospital in the country experiences some level of boarding. What differentiates high-performing systems is how effectively they manage the fluctuations between normal and atypical patient volumes. Solving for this variability requires more than faster discharges—it demands a continuous, end-to-end approach to flow that begins at triage and extends through inpatient placement. From real-time intake prioritization to seamless diagnostics coordination and smart bed assignments, optimizing throughput inside the ED is the next frontier.
By embracing predictive technologies, cross-functional workflows and full-journey visibility, hospitals can move beyond reactive, piecemeal interventions toward a coordinated, systemwide strategy. This shift enables health systems not only to better manage ED boarding but also to improve patient safety, staff satisfaction and the overall care experience.
Jason Harber is head of inpatient flow business, LeanTaaS.
A Premier Corporate Partner of ACHE, LeanTaaS is the market leader in providing AI-powered and cloud-based capacity management, staffing, and patient flow software and transformation services for health systems. For more information, visit ache.org/LeanTaaS.