Increasing Perspective on ED Boarding and Patient Care

By Matt Phillion

Connecticut’s recent decision to publicly report emergency department boarding data offers an important first step toward transparency. The state’s dashboard shows that nearly 40% of admitted patients waited for more than four hours for an inpatient bed in 2024—demonstrating the impact boarding has across hospital operations.

But while retrospective reporting is useful, real-time, operational intelligence can help health systems get ahead of bottlenecks, anticipate discharge barriers, coordinate downstream capacity, and proactively reduce boarding.

“I think what makes this really interesting is that the state is taking an approach from a statewide perspective,” says Dr. Hamad Husainy, CMO of PointClickCare. “For the longest time, organizations have tried to develop insight or visibility into wait times in the ED. The problem is how do you drive that data elsewhere?”

For example, Husainy says, if you’re looking at median boarding times, it eliminates the extremes on either end. But even the average number doesn’t tell you as much as you want to see.

“We look at average boarding times across all hours of the day. For example, if you look at the numbers at 3 a.m. in a well-staffed ED, the patients are getting in and out, so those numbers look artificially good,” he says. “What we really need to understand is real-time visibility. What is the situation right now? What does it look like at 6 p.m. on a busy holiday Thursday during flu season, versus first thing in the morning on a day in mid-May?”

If the data isn’t actionable or explainable, it risks being just another dashboard without as much meaning as it could have, Husainy explains.

“This is a very good first step, but there’s a lot more that needs to occur,” he says.

For the longest time, Husainy says, the EHR has been pointed to as a source of everything you need to know in the moment. But if every organization has its own EHR, how do we collate data and standardize it before you see the patient.

“We want to answer between 50% and 70% of your questions before you see that patient,” says Husainy.

Organizations and sharing data

To get there, Husainy says, ultimately you need to have all the hospitals on the same page and willing to share real-time data.

“It’s not a complicated process. It’s simple admission discharge or transfer data and a central repository or organization to manage this,” he says. “This is something that could really drive value for EMS organizations for patients to go to the right location knowing they are not going to wait for hours to be seen. It might also drive them to urgent care or their PCP if they know they will have to wait a long time.”

The issue this addresses, Husainy says, isn’t length of stay, but rather boarding itself.

“Boarding is different. When I admit a patient, how long are they going to be staying in my ED?” he says.

Boarding is a result of poor throughput process, Husainy explains.

“We need to be better able to have visibility within our patient population and trends that exist,” he says. “Such as earlier referrals to post-acute care or home health, investing in behavioral health or case management. While this is not overtly revenue-generating, what it does is improve the processes and allows patients to flow much better through that process. It allows hospitals to improve their numbers, which ultimately can be revenue-generating.”

Getting there means getting the right people who understand the story, Husainy says.

“The folks who are having this conversation are not just looking at a line item on a profit and loss sheet,” he says. “We have to get a more holistic view of what’s happening inside the four walls of the hospital. There are so many dynamic processes it’s hard for one group to have a firm understanding of it all.”

There’s also a need to bridge the clinical with the financial, Husainy goes on.

“How do we bridge that gap in knowledge?” he says. “This is where I lean on CNOs, CFOs, and others who are really able to bridge that gap and look at the art of what’s possible in the organization.”

This isn’t something every organization has the capacity for, though, he notes, as some are simply so cash-strapped that this sort of shift isn’t on the radar yet.

Barriers to visibility

Part of the issue is not knowing in real time what the story in the ED is, Husainy says.

“I think about this all the time: Is there a backlog in the ED? Are there patients boarding right now? Is the volume higher than it typically is? Are the post-acute care beds more full?” he says. “While this doesn’t need to be disseminated to the public, we need easy to understand, visible data points so they can say I’m going to this place or that place.”

The other question is how to apply that data and bring it into the workflow.

“We can’t create a solution with a thousand different sign-ons. How do we bring this into the workflow so we can see it in real time and make it easily useable for clinicians?” Husainy says.

Lastly, it needs to have an impact.

“If it doesn’t drive outcomes, it’s just a pretty book you put on the shelf that doesn’t really get used,” Husainy says. “How do we take that data and create resources to drive quality improvement?”

There needs to be a willingness to change across the board to make this sort of visibility and data sharing possible, Husainy says.

“Every time a leader in healthcare has a parent or family member that needs to wait in a hallway in an ED with those bright shining lights on them and a gown with a gap in the back. It’s interesting how, when that happens, we all lean in and say we’ve got to fix this,” says Husainy. “The issue today is there are thousands of patients just not getting the care they need in the appropriate location.”

To get there, we need to fill the care gaps, he says, whether that gap is inpatient mental health or having enough pediatric beds or more ICU beds.

“But, if we’re going to measure boarding, we have to take the next step and apply it. We need to dig into the why,” he says. “And then we need to allocate the funds to alleviate that problem.”

It’s a multi-factorial challenge and one where technology can be used to address some of those inefficiencies, Husainy says.

“There are so many transitions in healthcare, and we have technology that can drive patients to the most appropriate location, but it will require that everybody kind of comes together and gets on the same application, has the same data, in the same location at the same time,” he says.

Value-based care and risk-bearing contracts are going to continue to grow and be a part of this shift, Husainy says.

“We haven’t figured out a great way to address acute care in an unscheduled setting,” he says. “But I think we’re making headway. We’re learning more and more every day about how to provide care in places that are just as good as the hospital, whether that’s remote care, telehealth, or post-acute settings. Some will stick and provide value, some will be flash in the pan, but in the end, I think we’re getting better.”

It will require both financial motivation and a willingness to take the time and effort working hand in hand to move the needle, Husainy says.

“I think there’s a huge opportunity here, and I really appreciate what Connecticut is doing. They’re bringing awareness to a real issue,” he says. “The boarding study shows it increases morbidity, and it’s embarrassing for patients as they hang out waiting for a bed. I’d love to see more states follow and then, let’s not stop there. Let’s keep going and finish the task at hand.”

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.