JHHA

Abstract

Emergency department (ED) boarding prolonged stay in the ED after an inpatient bed is requested is associated with worse clinical outcomes and signals broader hospital flow constraints. This narrative policy analysis synthesizes organizational levers to reduce ED boarding while safeguarding quality and patient safety. Within the Madrid Regional Health Service (SERMAS), program contracts shape priorities and resource allocation; however, a predominant emphasis on human-resources cost containment, including seasonal ward closures, may counteract timely admissions. We propose incorporating an explicit performance indicator maximum 48 hours of ED boarding after admission request combined with demand-responsive pathways that avoid unnecessary hospitalization: short-stay units, high-throughput ambulatory surgery and invasive diagnostics, day hospitals, and rapid diagnostic units. Additional system strategies include early discharge supported by structured post-discharge follow-up, digitized intra-hospital consult scheduling, and statistical bed-management tools. Demographic aging requires tailored geriatric pathways to prevent avoidable admissions. When clinically appropriate, hospital‑at‑home offers comparable safety with improved satisfaction and lower readmissions. Digital interoperability between primary care and hospital admissions can enable direct admissions and reduce ED utilization. Finally, modular capacity and operational flexibility within EDs should be integrated into routine surge plans. Collectively, these measures align with integrated, people-centered care and can rebalance institutional priorities to improve patient flow, safety, and experience across the continuum of care.