The following is a guest article by Michelle Skinner, MBA, BSN, RN, Chief Clinical Executive at TeleTracking Technologies
Millions of viewers, including myself, watching the medical drama The Pitt, see a version of emergency medicine that feels painfully real. Patients wait for hours in crowded waiting rooms. Admitted patients stay in the ED because no inpatient beds are available. Clinicians move between hallways and stretchers, doing their best to care for patients in spaces never designed for treatment.
For those of us who have worked in emergency medicine, these scenes aren’t fictional exaggerations. They reflect daily reality.
Before working in health system strategy and technology, I spent years as a bedside nurse. I’ve stood at the foot of a stretcher in an overflowing ED asking the same question clinicians across the country ask every day: Why can’t we move this patient?
The answer is rarely simple. And it’s almost never just an ED problem.
Emergency department boarding is widely recognized as a hospital-wide patient safety and operations issue. ED boarding creates safety risks, decreases staff efficiency, and erodes the patient experience. Patients waiting in the ED for extended periods experience delays in definitive care, and these delays are linked to worse outcomes.
What viewers see in shows like The Pitt is a symptom of a broader throughput problem. The ED becomes the holding area when the rest of the hospital isn’t moving patients efficiently to the next stage of care.
Boarding isn’t solved in the ED.
It’s addressed by how well the system manages flow, especially discharge.
The Hidden Bottleneck: Delayed Discharges
Hospital beds are a finite resource. When a patient is medically ready to go home but hasn’t left yet, that bed cannot be used for the next patient arriving from the ED, surgery, or a scheduled admission.
Think of it like a game of Tetris: if the pieces at the bottom don’t clear, everything stacks up above them.
In hospitals, when patients who are ready to leave remain in beds, admissions back up, surgeries are delayed, and staff are forced to work around the constraint. Every additional hour a patient remains in a bed after they are clinically ready to leave has ripple effects throughout the system.
Delayed discharges are more than just an efficiency problem. They are a patient safety issue. They increase exposure to avoidable harm and contribute to delays in care, often in environments not designed for the patient’s needs.
Reducing ED boarding starts upstream with smarter, earlier, and more coordinated discharge planning. Research indicates that discharge timing and hospital throughput are directly linked to ED boarding, reinforcing that delays further downstream, rather than ED demand alone, drive congestion.
From Reactive to Predictive
Traditionally, discharge planning has been reactive. Teams identify discharge candidates late in the day, scramble to complete medications and paperwork, arrange transportation, and notify environmental services to prepare the room. Small delays compound, and by the time the bed becomes available, the ED is already backed up.
AI-based decision support is helping enable that shift.
Predictive tools analyze clinical and operational signals to identify patients likely to be ready for discharge and uncover barriers earlier in the day, enabling more proactive coordination. This early visibility allows case managers to arrange post-acute placement, pharmacists to prepare medications, and families to coordinate transportation in advance. Essentially, it creates shared situational awareness around the most effective throughput plan for the hospital at that moment.
More advanced platforms go further by using computational models to simulate hospital-wide operational impacts and support decision-making.
If ED volume is expected to surge later in the day, leaders can focus on discharges most likely to create capacity in advance. Instead of asking, “What happened yesterday?” organizations can ask, “What should we do next?”
That shift from hindsight to foresight is foundational to improving flow and reducing ED boarding.
Orchestrating the Discharge Workflow
A discharge isn’t just a single event; it’s a series of connected actions.
Discharge is not a single step. It requires coordinated action across clinical, operational, and support teams, from confirming readiness and preparing medications to arranging services, moving the patient, and turning the bed for the next admission.
When these steps happen in isolation, friction increases. When they are aligned, time shrinks.
AI-enabled workflow tools can initiate tasks, alert the appropriate team at the right time, and surface delays earlier. This decreases uncertainty for staff and shortens the time between “ready to discharge” and “bed available.”
Earlier discharges also enable earlier admissions. That timing shift matters. Moving patients home earlier in the day helps stabilize throughput and reduces late-day boarding pressure. While no single metric solves flow on its own, earlier, well-coordinated discharges are consistently associated with more stable throughput across the hospital.
Seeing the Whole System
One of the greatest barriers to timely discharge is fragmented visibility. Nurses might know who’s ready to leave, but they aren’t always aligned with downstream teams. Without a unified operational view, efforts remain siloed and don’t translate into a shared plan.
Technology that combines inpatient capacity, ED volume, OR schedules, staffing constraints, post-acute readiness, and community resources into a single view enables enterprise-wide coordination. It shifts teams from retrospective reporting to real-time decision-making.
With that visibility, organizations can act earlier to:
- Accelerate discharges when downstream services are ready
- Direct admissions to the most appropriate level of care
- Sequence tasks to minimize delays
- Escalate issues early to prevent downstream congestion
This is how capacity is created: not by adding beds, but by improving flow. This aligns with a well-established healthcare principle: improving patient flow is often more effective than expanding physical capacity.
Leaders can move beyond just observing bottlenecks to actively managing them. They can evaluate trade-offs, anticipate constraints, and align teams around a common operational goal.
People, Process, Technology
Technology alone cannot reduce boarding. Successful implementation demands alignment across three elements:
- People: Clinical teams must trust the information and stay central to decision-making; AI should assist, not replace, clinical judgment
- Process: Workflows must be intentionally designed; insight only matters if teams know how to act on it
- Technology: Real-time visibility, predictive insights, and workflow coordination enable proactive management
When these elements align, both operational and clinical performance improve together.
Capacity is More than Beds
ED boarding is often blamed on low-acuity patients or frequent utilizers. In reality, the issue is systemic. The ED reflects what is not moving elsewhere in the hospital.
Reducing boarding requires discharge planning that starts on day one, coordination across care settings, and a shift from reactive problem-solving to proactive flow management.
Shows like The Pitt are helping raise awareness of a long-standing challenge faced by clinicians and hospital leaders. But unlike what is often portrayed, there are genuine opportunities to tackle it.
We may not control the number of patients arriving at the ED, but we can control how prepared we are to move them through the system and home.
Capacity isn’t just about beds; it’s about flow. When organizations align people, process, and technology, they can reduce avoidable delays, support clinicians, and make patient movement through the system safer and more efficient.
