Solving ED boarding bottlenecks

Abstract Emergency Department (ED) boarding—the practice of holding admitted patients in the emergency department after a decision to admit has been made due to a lack of available inpatient beds—represents one of the most critical threats to healthcare quality, patient safety, and operational efficiency globally. Far from being an isolated "emergency room problem," ED boarding is an indicator of systemic hospital-wide and health system operational congestion. This article synthesizes current research and operational frameworks to examine the root causes, adverse consequences, and evidence-based solutions for mitigating ED boarding bottlenecks. By analyzing input, throughput, and output interventions—including early discharge protocols, real-time bed tracking, command center implementations, and post-acute transitions—we outline an integrated, multi-systemic framework to resolve ED boarding and optimize hospital flow.