From Every Angle: Emergency Department overcrowding

Start small to see big improvements in patient flow and utilization.

Tori Richie, Senior Consulting Director, Intelligence

ED overcrowding is a pressing issue for health systems across the U.S — and one that reflects broader systemic issues rather than isolated operational efficiencies.

“We like to talk about the ED as really being the canary in the coal mine,” said Tori Richie, senior consulting director, intelligence. “When we start to see breakdowns in the emergency department, that’s often a symptom of breakdowns elsewhere within the care continuum such as inpatient bottlenecks or ambulatory care gaps.”

That means hospital leaders must identify and target pain points ranging from workflow optimization to discharge timing to patient education and navigation. It’s a lot — which is why Richie recommends starting small.

“Pick a pilot. Track your performance and improvement with that pilot and scale from there,” she said. “Don’t try to do everything at once."

Strategies to consider:

• Optimize inpatient flow and discharge timing: Boarding issues arise when patients wait in the ED due to full inpatient units. Hospitals should find opportunities to improve inpatient throughput, consider length of stay optimization — for example, coordinate inpatient discharge timing with ED peak hours to free up beds and reduce ED backup.
• Expand and streamline ambulatory access: Many patients use the ED because they lack timely access to outpatient services. Ambulatory expansion strategies should address chronic disease management, anticipate care needs of aging and comorbid populations, and offer services for patients undergoing treatment (like chemotherapy) who may otherwise go to the ED for manageable side effects. For example, oncology urgent care centers have been launched to manage a range of common complications and treatment side effects for cancer patients, an initiative proven to reduce ED utilization, lower healthcare costs and reduce interruptions to cancer treatment due to side effects. It’s important to focus on same-day access, extended hours and geographic coverage. One possible solution: hub-and-spoke ambulatory models where patients can receive comprehensive care at one site — which reduces fragmentation and unnecessary ED visits. “Unless you solve access issues upstream, you will continue to see folks flow through to the emergency department,” Richie said.
• Implement technology-enabled workflow optimization: Many hospitals are leveraging predictive analytics to anticipate surges in ED volume and identify service gaps. Focus investment on high-need patient cohorts (e.g., chronic disease, cancer, behavioral health) through specialized urgent care models to divert them from ED use. Creative tools like ED “stoplight” systems signal staff on patient status at a glance, which enhances throughput and wait-time transparency — like posting ED wait times on websites or billboards — helps distribute demand across locations.
• Improve patient navigation and education: Consumer-centric approaches help patients understand where and how to access appropriate care. For example, AI chatbots can guide patients to the correct site of care based on symptom severity, and real-time virtual triage and digital waiting queues — like text notifications and mobile alerts — can reduce inefficiencies. Also, educating frequent visitors (such as those with chronic conditions) on more appropriate sites of care helps reduce inappropriate ED utilization. Integrating access, throughput and care management means higher quality experiences, more efficient encounters and fewer exacerbations of chronic illness due to better longitudinal management.
• Address barriers for uninsured or underinsured patients: Fear of costs or being turned away leads uninsured individuals to rely on the ED. Possible solutions include community-based mobile or street teams, free clinics and upstream care management.
• Emphasize change management and leadership alignment: Major interventions (e.g., surgical scheduling changes) require early buy-in from key stakeholders, such as surgeons and operational leaders. Assess organizational structure to support cross-functional collaboration.

Break the boarding cycle through coordinated action.

Roy Boland, Vice President, Consulting

Why it matters: One of the biggest challenges in EDs is that boarding — a holding pattern for patients as they wait for an inpatient bed or transfer — has exponentially increased across the country due to hospital capacity limitations, patient volume increases and slower discharge processes. It’s no surprise that this leads to reduced quality care (increased morbidity and mortality), longer lengths of stay, higher hospital costs, poorer patient experience and lower operational efficiency.

The pinch point is the tension between financial viability and operational functionality within hospitals explains Roy Boland, vice president, consulting, at Kaufman Hall, a Vizient company.

“Hospitals can’t afford to run at their desired 80% inpatient volume and maintain a sustainable margin,” he said adding hospitals often operate at or above 100% capacity, forcing EDs to board admitted patients. “Surgeries are the biggest revenue generators requiring inpatient stays, so EDs end up absorbing the flow.”

Boarding is not just an ED-only problem. It requires cross-departmental interventions, especially in inpatient discharge and length of stay management. But Boland says there are meaningful tactics in the ED that can improve patient flow — if they are coordinated interdependently.

“In the ED, three variables need to be in lock step: The number of direct care nurses, providers and the physical capacity,” Boland said. “Anytime you have a miss on any of those, the most constrained resource consistently impedes the flow.”

Strategies to consider:

• Align staffing to daily demand curves is non-negotiable. Chronic understaffing — especially in nursing — has become a normalized issue in many EDs. Even small gaps in morning staffing can snowball into major throughput issues later in the day. Because patient arrival patterns are remarkably consistent day to day, staffing and operational decisions should anticipate bottlenecks before they emerge. Hospitals achieving better ED flow are leveraging AI and predictive modeling (e.g., Python-based analyses) to forecast hourly volume and proactively align nurse, provider and physical space capacity. Leaders should plan proactively for staff callouts and avoid reactive closures of low-acuity zones, which often backfire on efficiency.
• Implement smart triage and fast-track models. Emergency Medical Treatment and Active Labor Act (EMTALA) regulations, limit the ability to divert low-acuity patients, ensuring no one is turned away from care. However, EDs can implement fast-track units for Emergency Severity Index (ESI) level 4 and 5 patients. These units enable quicker throughput and discharge without compromising care. This operational segmentation ensures the sickest patients receive timely attention while low-acuity cases don’t congest core ED operations.
• Reduce door-to-doc time. Point-of-care testing (e.g., high-sensitivity cardiac troponins and bedside ultrasound) can accelerate decision-making for common ED presentations like chest pain and abdominal complaints. However, the most impactful operational lever remains reducing "door-to-doc" time, which drives all outcomes. Getting the decision-making clinician to patients quickly reduces length of stay and lowers the number of patients leaving without being seen. Telemedicine also can play a vital role, especially in behavioral health and neurology, where many organizations struggle to have sufficient on-site support. Telepsychiatry and telestroke services help reduce wait times, expedite assessments and care decisions, and minimize costly delays tied to specialist availability.
• Reassess observational care regularly. Observation patients often linger due to poor process oversight. Providers may put patients in observation for social reasons or physician uncertainty, even if they don’t meet criteria. Regular reassessments (every three to four hours) and prompt provider engagement can lead to earlier discharges or appropriate inpatient upgrades. Leaders should ensure these processes are structured and actively managed.
• Embed case management. Embedding case managers into ED teams helps enable safe discharges for patients who don’t meet admission criteria but still need support. Services such as home health, medical equipment or access to post-acute care (e.g., skilled nursing facilities) reduce readmissions and open beds for higher-acuity needs.
• Strengthen chronic care and prevention. Preventive and chronic care management — particularly for conditions like diabetes and congestive heart failure — can help mitigate repeat ED visits. Tactics include remote monitoring, nurse navigators and post-discharge outreach. Ensuring outpatients attend follow-up appointments, take medications and maintain healthy routines (e.g., monitoring diet, blood sugar and blood pressure) can prevent avoidable exacerbations. “These practices help catch patient problems early,” Boland said. “It’s someone tapping them on the shoulder to remind them: Watch your weight, take your medicine, don’t forget your follow-up appointment. It reduces ED readmissions and protects inpatient beds.”

Identify your biggest ED pain points — then implement AI to help solve them.

Erik Swanson, Senior Vice President, Consulting

Technology is rarely a cure-all. But when it comes to reducing ED overcrowding, artificial intelligence is in many ways a prime antidote.

But first things first.

“The big failure with any AI tools is that too many leaders adopt a solution and then look for a problem,” said Erik Swanson, Senior Vice President, Consulting. “You need to identify the problems first, and then you can determine the best resources to help you address them.”

Swanson outlined three key categories of AI applications that can assist in lowering ED utilization:

• Workflow and resource management tools: These are AI resources that optimize staffing, predict patient volume and allocate resources more effectively to prevent bottlenecks.
• Clinical decision support tools: These tools assist clinicians with real-time alerts and insights (e.g., sepsis prediction, early triage, social care referrals), improving patient flow and outcomes.
• Strategic planning tools: AI can model the effects of system changes (e.g., expanding ED capacity or adding urgent care centers) to guide long-term planning.

Before implementing any clinical or nonclinical AI solution, healthcare leaders should ask themselves several important questions, Swanson said, including:

• How should we develop and deploy AI tools? Organizations should have a strong AI strategy and use that to determine if they should build AI tools internally or in partnership with vendors. The recognition of your system’s strengths, weaknesses and competencies is critical, and ensuring alignment with local needs and strong engagement from physicians and staff is paramount.
• What is our best starting point? Swanson recommends most institutions begin with operational/logistical tools, not clinical decision tools. That’s because nonclinical, administrative applications tend to be less complex to implement, have lower risk in terms of security and accuracy, and more effective at identifying root problems (e.g., space constraints vs. patient mix, and can often be implemented more quickly with humans in the loop.
• How should we best identify pain points? Use standard ED KPIs (e.g., leaving without being seen rates, time-to-provider, length of stay, observation status metrics) to identify pain points and let these data points guide where AI can offer the most value.
• How do we determine financial and operational feasibility of AI tools? Considering hospitals face high hurdles for new tech investments, AI projects should clearly tie to financial/operational KPIs, demonstrate ROI before scaling, and be tracked to ensure causality between AI use and improved outcomes.
• Will this process be as painful as EHR rollouts? The good news, Swanson said, is no — deploying AI tools is comparatively painless. AI tools are cheaper and faster to implement, failures are less costly, and many tools can integrate with existing data systems and improve over time as data quality improves.

But don’t forget, he said — the AI tools you implement are only as good as your data governance.

“Many of these tools, particularly the clinical decision support tools, are reliant upon high-quality data,” Swanson said. “If your EMR has a lot of issues, adding AI on top of it is not going to solve your problems — and in fact, may make them all that much more difficult to solve.”

Devote resources to behavioral health to drive long-term gains.

Jen Goff, Director, Intelligence

Why it matters: Access, stigma and complications with treatment are all contributing factors for why a behavioral health patient may find themselves in the emergency department.

Due to a shortage of behavioral health providers, many patients struggle to access care — either because it’s hard to find an available provider or their insurance offers limited options. Even if they have a primary care provider, the stigma surrounding mental health can make opening up feel overwhelming. Often, individuals don’t realize they’re facing a mental health issue until they end up in the emergency department — whether because of suicidal thoughts or attempts, substance abuse or complications from an eating disorder.

“The issues around behavioral health are multifaceted,” said Jen Goff, director, intelligence. “Often people don’t want to talk about mental health or substance abuse until they’ve landed in the emergency department when their symptoms have worsened.”

There are also patients who have been diagnosed and are following treatment plans, but when the treatment isn’t effective or there’s poor adherence, they may experience another episode that leads them back to the emergency department.

Challenges with inpatient psychiatric bed capacity also contribute to ED overcrowding by requiring behavioral health patients to board the ED.

According to the Vizient Clinical Data Base (CDB), adult behavioral health-related visits account for 5-6% of all emergency department visits, and 70% of those visits are discharged to the home. However, behavioral health patients have the highest emergency department length of stay, with an average of 9-10 hours compared to the 4-5 hours average for all emergency department patients. Worse, yet, the 2025 Sg2 Impact of Change forecasts a 12% growth rate of behavioral health patients’ visits to the emergency department over the next 10 years.

“Behavioral health patients’ lengths of stay are longer, causing them to occupy a bed for longer than the average medical patient and contributing to ED overcrowding,” Goff said. “When we focus on improving behavioral health patient outcomes, we’re able to improve overall patient care, decrease emergency department readmission rates and improve ED capacity.”

Strategies to consider:

• Make use of Emergency Psychiatric Assessment, Treatment and Healing (EmPATH) units. Often staffed with behavioral health providers, these units are designed specifically for behavioral health patients in crisis. EmPATH units are co-located within the hospital, in close proximity to the ED, to allow for efficient triage and referral. The EmPATH team triages, assesses and develops treatment plans with the goal of stabilization. Patients may remain in the unit for up to 23 hours before being discharged or transferred. This model has been shown to improve ED throughput, reduce psychiatric hospitalizations and enhance overall patient outcomes.
• Establish behavioral health urgent cares (BHUC). These care sites function similarly to urgent care centers, allowing patients to voluntarily walk in for behavioral health services and receive rapid access to care. BHUCs triage, assess and link patients to a follow-up plan.
• Integrate behavioral health into primary care. This approach embeds behavioral health providers in primary care to address both physical and behavioral health needs in a coordinated, patient-centered approach. This model enhances access to mental health services, improves communication among providers and leads to more effective care. “This is more of an upstream approach that many health systems are adopting, because it allows primary care providers to provide earlier intervention with their patients, find them the care they need and keep them out of emergency departments,” Goff said.
• Improve your psych consult workflow. Consider how psych consults are currently managed within the emergency department and determine where opportunities to streamline may exist. The faster a patient can get their consultation and be assessed, the faster they can be triaged, provided with a care plan and discharged. “Some organizations have been adding virtual capabilities by partnering with behavioral health companies to provide these consults,” Goff said. “Others have embedded their own advanced practitioner on-site with access to a psychiatrist. It just depends on what works best for the hospital and what will make it possible to assess these patients and get them the most appropriate care quicker.”
• Partner with mobile crisis services. A collaborative effort among behavioral health providers, law enforcement and EMS, these teams aim to deescalate behavioral health crises when responding to a situation on site, rather than bring the patient directly to the emergency department or jail. These teams are typically staffed by behavioral health professionals — such as social workers, psychologists or psychiatrists — who can assess individuals and provide immediate care.
• Utilize crisis hotlines. Leverage crisis hotlines to triage and assess behavioral health patients, helping determine the level of care they need. This approach can assist in deescalating crisis situations and ensuring timely, appropriate support.

“Behavioral health in the emergency department has been a challenge for many years, and everyone’s trying different things to help, so there are many different solutions. But I think it really comes down to your organization and local market to drive what will really work,” Goff said. “The good news is there are so many community partners out there willing to collaborate in this area that you won’t have to build it all yourself or solve this problem on your own.”

Plan ahead for discharge — starting at admission.

Brian Pisarsky, Managing Director, Consulting

Why it matters: Discharge planning starts upon admission — or it should, said Brian Pisarsky, managing director, consulting. But for reasons like inconsistent communication between teams or unclear diagnoses, it doesn’t always happen.

And delayed discharges can add up in a big way.

“One thing we’re finding across healthcare organizations is those inpatient stays that have the most excess days above the benchmark are patients who are staying between five and 15 days,” Pisarsky said. “So, if we can reduce 10 days to eight, or four to three by moving inpatient beds quicker — that’s where we can see the greatest impact on ED throughput.”

The sooner in the ED that discharge planning for the next phase of care begins — whether that be care at home, in a nursing home or inpatient admission — the quicker the patient gets the care they need and the more efficiently the ED operates.

“Many times case management is too reactive instead of proactive,” Pisarsky said. “The discharge process needs to happen along the way during the inpatient stay — it can’t wait until the day the inpatient physician finally says, ‘OK, yeah, they can go tomorrow,’ and then all of this discharge work begins.”

Strategies to consider:

• Assess the patient and involve caregivers. During the initial assessment, bring the patient’s caregivers into the discussion, whether that’s their spouse, child or another caregiver, neighbor or guardian. Understand the length of time most patients who present with a similar diagnosis stay in inpatient care and determine a plan from there, taking into account any anomalous symptoms or conditions. “There’s nothing worse than getting to the end of a stay, and the patient says, ‘Well, I’m not going to the nursing home,” Pisarsky said. “Bringing in the caregiver or family from the start can alleviate some of these potential setbacks. Timely, scripted, and team-driven patient and family meetings are an essential element to the discharge planning process”
• Identify complexities. Perhaps the patient has no family or they’re in need of a guardian. Understanding a patient’s individual needs is critical to developing a discharge plan. “A large portion of patients are going to go home with minimal needs and identifying that subset of patients creates incremental capacity with less lift that in turn can help manage these more complex patient needs that take more time or coordination,” Pisarsky said.
• Conduct multidisciplinary rounds. Conduct a review of all patients within a facility to better understand bed capacity and minimize care gaps. For each patient, the care team — including physicians, nurses, case management and social workers as well as appropriate ancillary departments — should ask themselves:
  • What’s the patient’s plan for today?
  • What’s their plan for the rest of their stay?
  • Are medical milestones improving during their stay (pain, mobility, diet, etc.)?
  • What’s their discharge plan and what needs to happen today to move this patient towards their safe and timely discharge?
• Track and measure. Track observation and inpatient metrics to determine success and opportunities for improvement. Evaluate observation length of stay, inpatient length of stay and ED metrics to gain a deeper understanding into where patients are being held up and where they transition to after the ED.

“Patients and families shouldn’t have to board in the ED; they deserve timely and high-quality care,” he said. “Improving ED operations and decreasing capacity constraints leads to better patient care, satisfaction and outcomes. There are fewer opportunities for errors, and timely and efficient patient throughput is good for both the patient and the healthcare organization.”