Maintaining Emergency Department Operational Efficiency and Capacity Management in the Era of ED Overcrowding and Inpatient Boarding

Abstract

Inpatient boarding in the Emergency department (ED) has long been associated with reductions in patient safety, patient and staff experience, and hospital operational performance. Boarding increased sharply during the COVID-19 pandemic and has remained elevated, representing continued mismatch between demand for unscheduled acute care and constrained inpatient capacity. Although the operational consequences are most visible in the ED (crowding, extended length of stay, increased left-without-being-seen rates, and diminished patient satisfaction), the primary drivers and durable solutions span the full hospital and health system continuum. This review synthesizes evidence-based interventions to mitigate boarding and preserve ED functional capacity across three operational levels: (1) ED-focused strategies that optimize intake, throughput, and output, (2) hospital-level capacity and throughput initiatives that reduce inpatient length of stay and improve bed turnover, and (3) healthcare system approaches that coordinate patient flow across multiple hospitals through centralized command centers, load balancing, transport integration, and real-time surge management. We highlight implementation experience from Brown University Health’s Capacity Management and Access Center (CMAC) as an example of coordinated, multi-tiered capacity governance. Sustainable improvement requires shared accountability beyond the ED, continuous KPI monitoring, and culture change toward system-first capacity management to protect access, safety, and quality.