How to Reduce ED Boarding and Improve Bed Capacity in Hospitals
Key takeaways:
- The causes of ED boarding lie outside the emergency department, with inpatient units.
- Therefore, ED-based interventions have limited success in alleviating ED boarding.
- The most effective solutions will address discharge timing (such as moving discharges to earlier in the day), and eliminate practices such as batching.
- Rapid Room Turnover addresses these issues, by clearing away manual obstacles (such as documenting discharges and sending alerts to environmental services), streamlining workflows and ensuring higher room availability.
ED boarding, by the numbers
Over the past several decades, emergency department boarding has increased dramatically.
In one study of 46.2 million hospitalizations across 1,500 hospitals, researchers found that from 2017-2024, 25% of all admitted patients waited four or more hours for a bed; during winter months, this number was approximately 35%. The same team found that even the lowest rates of boarding patients in 2024 were higher than the peak boarding rates of patients in 2017 through 2019.
When it does occur, ED boarding is also growing in length. Another review of EHR data from 56 EDs across 17 health systems from June 2024 to May 2025 found that of the 492,000 admitted patients, nearly 53.6% boarded for at least four hours. Handoff delays ran to almost a full day in length, and up to 17% of admitted patients (85,000) went at least four hours without being seen by an inpatient team; in the most extreme cases, patients waited 24 hours or longer.
Unfortunately, this increase in ED boarding frequency and length also conflicts with established best practices. According to Joint Commission recommendations, ED boarding should not exceed four hours for health and safety reasons; prolonged boarding times are associated with severe consequences including mortality, morbidity, treatment delays, and more.
ED boarding is an inpatient problem, not an ED problem
Multiple studies have determined that the root causes of ED boarding are in inpatient units, rather than the ED itself. One pivotal 2003 report in The Annals of Emergency Medicine modeled ED patient flow as a chart, with inputs, throughputs, and outputs.
- Inputs included emergency care in the ED, which encompassed unscheduled urgent care and safety net care.
- Throughputs included diagnostic testing and ED treatment, essentially focusing on patient length of stay in an ED.
- Outputs included a wide array of potential results, such as leaving without being seen (LWBS), transfer to ambulatory care, inpatient admission, and more.
Outputs were the most crucial. While ED boarding was exacerbated by factors such as staffing shortages, many key issues lay in inpatient departments, including a lack of available, staffed inpatient beds, post-discharge delays in cleaning and turning over rooms, and an inability to discharge patients in a timely manner to post-acute care facilities.
As a result, ED-based interventions have little effect on the numbers; one report found that expanding ED capacity simply enabled more patients to be boarded and further strained already overburdened staff. Without addressing outputs, specifically where it concerns inpatient units, hospitals cannot alleviate ED boarding.
How smoothing discharges helps reduce ED boarding
There are a wide range of interventions (primarily on the inpatient side) to address different aspects of the issue, but the most relevant is smoothing discharges.
While hospitals admit patients 24 hours a day, many only discharge patients between 10 AM and 5 PM. Unfortunately, this backs up demand for beds by noon, when discharges have not occurred for 12+ hours. Missing this narrow window also delays discharges to the next day, leaving one less available bed for admitted patients.
A related issue is batching discharges: when clinicians complete discharge orders all at once, instead of on a rolling basis, this tends to drive up LOS for patients. The consequences can manifest downstream; for example, if an EVS team gets multiple simultaneous requests for cleaning, they can likely only complete 1-2 on time.
By smoothing discharges, or discharging more patients earlier in the day, researchers found that ED boarding decreased from 27 to 57%, while length of stay for ED patients decreased by 7-14 hours. Additional research concluded that discharging patients earlier reduces inpatient waits by up to 25%, though this metric is disputed by other studies.
Real-time visibility into bed and room status
However, smoothing and other time-based interventions, such as discharges before noon (DBN), cannot improve length of stay by themselves.
Instead, automation and optimization is required. While many EHRs can log the timestamps for steps in the discharge process (orders, cleaning, and availability), many of these actions are still manual. As a result, there is significant lag between when a discharged patient physically leaves the hospital and when their bed is ready for the next admitted patient — which contributes to ED boarding.
Therefore, hospitals need a technology that automatically detects discharge timestamps and provides real-time visibility into bed status. This requires fusing two data sources: the admission, discharge, and transfer feed, which tracks patients moving through the system, and live, room-level data (via RTLS) to confirm whether beds are occupied, empty, being cleaned, or ready.
Rapid Room Turnover
In addition to smoothing discharges, hospitals can also do their best to reduce batching. Kontakt.io’s Rapid Room Turnover was designed to alleviate this exact problem.
Rapid Room Turnover uses RTLS to detect when a discharged patient physically leaves the hospital and then sends an AO3 message; depending on the customer hospital’s preferences, this notification can be routed through their EHR to inform EVS. This replaces the manual documentation that typically starts that process, speeds up room availability, and allows admitted patients to move into that room hours sooner.
On average, 90 minutes elapse between a patient physically leaving and their discharge being documented, time that would force an ED patient to board while waiting for that exact bed. A hypothetical, 200-bed hospital using Rapid Room Turnover can recover up to $2.6 million in annual operating cost reductions, and roughly 400 additional ED visits captured each year; these patients would otherwise have left without being seen.
Paired with smoothed discharge timing and real-time bed visibility, Rapid Room Turnover is the piece that actually converts a freed-up bed into a shorter wait in the emergency department.
