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@mdaware.orgOct 7, 2026, 9:33 PM

need senior leadership (ie, hospital CEO) buy in to address boarding

the CEO needs to care about avoiding hallway care because it’s lot dignified and improve boarding because it hurts patients

@arjunvenkatesh.bsky.social #ACEP26

@mdaware.orgOct 7, 2026, 9:31 PM

a lot of high level stats can be misleading, hide heterogeneity

eg some hospitals are expanding but closing in the areas, beds per pop is flat but maldistributed (“lying with averages”)

@arjunvenkatesh.bsky.social #ACEP26

@mdaware.orgOct 7, 2026, 9:25 PM

great anecdote from @arjunvenkatesh.bsky.social :

had a resident lay in a hospital bed to see what it’s like. they lasted 2 min.

being a hallway patient is a bad experience

#ACEP26

@mdaware.orgOct 7, 2026, 9:22 PM

we think of hallway patients as simple & fast but they’re really the same as average ED patients, eg 60yo w abd pain needing a CT

@arjunvenkatesh.bsky.social #ACEP26

@mdaware.orgOct 7, 2026, 9:20 PM

Audience q: why aren’t hospitals building more beds?

expensive to build hospital beds (both due to regs and fancy foyers etc), and focus on outpatient care ($) which means lack of focus on declining inpatient reimbursement

@arjunvenkatesh.bsky.social #ACEP26

@mdaware.orgOct 7, 2026, 9:17 PM

hospitals will likely try for quick fixes but quickly learn that it’s all the boarding submeasure and it’s not just an ED problem

@arjunvenkatesh.bsky.social #ACEP26

@mdaware.orgOct 7, 2026, 9:15 PM

good chance hospitals are going to fail ECAT on ~35% of patients

broken into 4 scores: adults w/wo mental health condition, and kids w/wo mental health conditions; adult nonmental health is the key category the ED can work on

@arjunvenkatesh.bsky.social #ACEP26

Emergency Care Access Based on a Proposed CMS National Quality Measure ED visits with failure on ECCOl composite score s 30 20- 10 With mental health diagnosis • Age <18 y - Age ≥18 V Without mental health diagnosis --•-- - Age <18 y ----- Age 218 y - Overall 2017 2018 2019 2020 2021 Year 2022 2023 2024 2025 еHтCAGо26 JAMA Health Forum. 2025:6(4):e250417. doi:10.1001/jamahealthforum.2025.0417
@mdaware.orgOct 7, 2026, 9:12 PM

EVAT reporting in 2027 is voluntary, tied to public reporting in 2028 and goes into star ratings (and probably payment)

@arjunvenkatesh.bsky.social #ACEP26

The Stakes - Timeline & Financial Impact While Reporting Begins in 2027, Prep Must Start Now 2.0% Payment Reduction Penalty Hospital Star Ratings Are Also at Risk 年可日 0年日日 Performance during CY 2028 will directly impact hospital payments in CY 2030. Reporting In GY 20arls ootondl. Hospitals that fail to meet OQR reporting requirements will see this reduction in their annual payment update, including the new ECAT measure. CMS Is now also penallzing hospitals more for poor performance in the Safety of Care measure group.
@mdaware.orgOct 7, 2026, 9:08 PM

ECAT: new CMS boarding quality measure

failing any one of these is a penalty

@arjunvenkatesh.bsky.social #ACEP26

ECAT: Emergency Care Access and Timeliness THE SOLUTION: UNDERSTANDING THE NEW ECAT eCQM A New Composite Measure of ED Throughput It uses EHR-extracted data to capture multiple dimensions of ED throughput and access. FAILURE TRIGGERS Excessive Wait Time Patients wait >1 hour from arrival to be place ina Extended Boarding Admitted patient stays h the ED for >4 hours after admission order. Prolonged Stay Total time from ED arrival to departure is zo loure Left Without Evaluation Patient leaves the ED before being evaluated by a qualified clinician. 1 ст о 26 Source: D21
@mdaware.orgOct 7, 2026, 9:06 PM

inpatient docs taking care of boarders in the ED does help LOS & boarding

@arjunvenkatesh.bsky.social #ACEP26

Solution #12: Inpatient coverage of boarding patients Admitted ED patients covered by a hospitalist service while boarding have shorter LOS Intervention: Output Evidence Waiting Room Time LWBS LOS Boarding Safety/Mortality - 1125h. CHICAGO26 Source: Kobayashi, JHM, 2019
@mdaware.orgOct 7, 2026, 9:05 PM

building hospital beds helps boarding! but bigger aging trends mean we can’t (easily) build our way out of this, and it’s expensive (and not what we’re doing)

@arjunvenkatesh.bsky.social #ACEP26

Solution #11: Build hospital beds Intervention: Output Evidence Waiting Room Time LWBS LOS Boarding Safety/Mortality Patient Satisfaction нісясо26 US Hospital Occupancy † 11% # Staffed Beds in US Hospital | 16% Projected national hospital occupancy 85% Hospital bed shortage threshold Reaches 85% by ~2032 70% 75.3% (2023-2024) 50% 2020 2025 2030 Assumes aping population increase: hospitalizations while staffed bed supply and hospitalization rate stay unchanged. 2035 Source: Leuchter, JAMA Open, 2025
@mdaware.orgOct 7, 2026, 9:05 PM

inpatient discharge lounges have face validity and should work but are understudied

@arjunvenkatesh.bsky.social #ACEP26

Solution #10: Inpatient Discharge Lounge Discharge Lounges do not increase safety events, but are used too infrequently to evaluate Inpatent Bed Discharge Lounge Department Bed Intervention: Output Evidence Waiting Room Time - EWBS LOS Boarding Safety/Mortality or elher senvices Loange Poiest 3 hseen Pethet2 i noved ts an Pathet 1 is omaties CHICAGO26 Source: Franklin, Annals EM, 2020
@mdaware.orgOct 7, 2026, 9:01 PM

inpatient hallway boarding can work - the secret is 1/4 of upstairs hallway patients magically get a bed faster when the patient is already there

but hard to implement until it’s too late, already way above optimal occupancy
@arjunvenkatesh.bsky.social #ACEP26

Solution #8: Inter-campus Load Leveling Intervention: Output -vdence Waiting Room Time LWBS LOS Boarding Safety/Mortality CHICA0O26 Level Loading Improves the Spectrum of ED Flow Primary ouccome: Throughput of load-leveled patients. Patients who were load-leveled REDUCED -7.83h, 95% CI(-8.35. -731) Inpatient Length of Stay UNCHANGED 0.04 days (-0.18, 0.27)T Source: Dilip, AJEM, 2025
@mdaware.orgOct 7, 2026, 8:59 PM

inter campus load leveling can work (Yale’s are only a mile apart) but patients need to know they are getting the same level of care

much easier to convince patients to be transferred to the other site IF the patient had boarded in the ED before

@arjunvenkatesh.bsky.social #ACEP26

Solution #8: Inter-campus Load Leveling Intervention: Output -vdence Waiting Room Time LWBS LOS Boarding Safety/Mortality CHICA0O26 Level Loading Improves the Spectrum of ED Flow Primary ouccome: Throughput of load-leveled patients. Patients who were load-leveled REDUCED -7.83h, 95% CI(-8.35. -731) Inpatient Length of Stay UNCHANGED 0.04 days (-0.18, 0.27)T Source: Dilip, AJEM, 2025
@mdaware.orgOct 7, 2026, 8:56 PM

if you use ED obs really well (avoiding inpatient admissions) they can help boarding

in practice it can be a lot of hospital-based outpatient care (eg specialty consults, imaging) that could be outpatient if the outpatient system worked

@arjunvenkatesh.bsky.social #ACEP26

Solution #7: ED Observation Unit Intervention: Output Evidence Waiting Room Time LWBS LOS Boarding Safety/Mortality .EHICAG026 EDOU reduce boarding across 3400 1 occupancy rates 200 Source: Ok, AJEM, 2020 Psychiatric OU reduce psych boarding Source: Parwani, AEM, 2018
@mdaware.orgOct 7, 2026, 8:54 PM

building more ED spaces doesn’t help ED LOS

flow smoothly, ie surgical schedule smoothing, is great if you can convince surgeons to operate on Fridays / weekends, and the infrastructure for it (eg more transporters on weekends)

@arjunvenkatesh.bsky.social
#ACEP26

Solution #5: Build ED beds Intervention: Input Waiting Room Time LWBS LOS Boarding Safety/Mortality Patient Satisfaction Average ED lenath of stay (minutes Bigger ED Paradox More beds do not necessarily mean shorter length of stay. 280 250 Care Paradox: 28 beds → ~18 mil LONGER LOS 240 28 beds 23 beds 220 • 28 beds I 23 beds Discharge rate 3 → 4 patients/hour: ~22 min SHORTER LOS 200 Hospital discharge rate (patients/hour) Source: Khare, Annals of EM, 2009Solution #6: Surgical Smoothing/ Demand Management So effective, but so difficult Intervention: Throughput Evidence Waiting Room Time LWBS LOS Boarding Safety/Mortality Typical clustered schedule Smoothed schedule a hospital can enhance patient access in three important ways - by increasing inpatient bed capacity, by engaging in active discharge of suitable patients, and by improving their inpatient scheduling process 000826 Source: Singh & Terwiesch, 2017
@mdaware.orgOct 7, 2026, 8:54 PM

split flow helps patients get seen but doesn’t help boarding

hallway care gets patients seen but with worse care, worse boarding

@arjunvenkatesh.bsky.social #ACEP26

Solution #3: Split-flow/Fast Track Fast track sees fast patients *...the intervention successfully reduced the number of ED stays with LOS 24 hours. However... the intervention did not seem effective in helping the patients who needed it to access an appropriate hospital bed in a reasonable amount of time (<8 hours). Intervention: Input Evidence Waiting Room Time LWBS LOS Boarding Safety/Mortality Source: Chrusciel et al. BMJ Open, 2019|Solution #4: Hallway Patients Intervention: Throughput Evidence Waiting Room Time LWBS LOS 1 Boarding Safety/Mortality Fast for Real or Just a Feel? Hallway placement earty throughput metrics Improve, but total ED length of stay is longer. Door-to-bed Bed-to-provider Provider-to- Al discharges Carac discharges shemity symplone hital steps are faster - slower While hallway treatment spaces expedite initial placement, they do not improve, and may even hinder, overall ED throughput. Contrary to expectations, these findings suggest that expedited care in hallway spaces could paradoxically hinder operational efficiency and timeliness. Source: Dilip JACEP Open, 2025
@mdaware.orgOct 7, 2026, 8:48 PM

ambulance diversion doesn’t help ED boarding, hurts patients

physician in triage: some minor improvements with low acuity patients, LWBS but *worse* boarding

@arjunvenkatesh.bsky.social
#ACEP26

Solution #1: Ambulance Diversion Intervention: Input Evidence Waiting Room Time LWBS - LOS Boarding - Safety/Mortality 기 CHICAGO26 Ambulance diversion ban in MA did not impact ED or hospital operations Source; Burke, Annals of EM, 2013Solution #2: Physician in Triage (PIT) Intervention: Input Evidence Waiting Room Time LWBS Boarding Safety/Mortality CHTCAGOZ6 A physician in triage improves triage flow Whadcd Impact of a Screening Physician on ED Operational Outcomes 12 months pre-physician screening vs post-physician screening ucone Pre-physician Post-physician Mo acuty procns Median ED LOS 274 min POR 241-5590 348 mit OQR 219-5300 $ 26 min Huny oooe Media EO LOS 339 min OOR 221-525 333 min 984472471 4, 5 min belt witneut debae 3.19% 05N C13.01-3.300 1.78% 1.41 percentage points Median boarders per day OQR 18-27) 1 1 per day Median boarding hours (QR 56.6-139.3) 100.2 004 541°19030 f 7.2 hours/day iei Teoie 2 Valves ows as esedien 000 ecege (t, Pipee as see th%c Source: Soremekun, AJEM 2012
@mdaware.orgOct 7, 2026, 8:44 PM

all sorts of factors in ED boarding and outcomes

@arjunvenkatesh.bsky.social #ACEP26

Hospital Capacity Crisis: ED Outcomes Structural barrier 曲 Hospital Output • Discharge blocking (SNF, STR) Hospital Throughput • Avoldable Care Hospital Input ED outcomes • Transfer needs • Boarding Operational • Recovery expectations • LOS accountability • Bed and service assignment • Prolonged LOS Financial • Perceived readmission penalty • Staffing costs • Scheduled > UnScheduled • LWBS Structures. Operations. Finances
@mdaware.orgOct 7, 2026, 8:43 PM

ED crowding / boarding results from hospital o & health system dysfunction and lack of capacity (flow)

it is NOT low acuity patients

ED wait times have functionally replaced the Ottawa ankle rule

@arjunvenkatesh.bsky.social #ACEP26

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