Reducing Emergency Department (ED) Boarding Time Through Lean Redesign of the ED-to-Inpatient Admission Pathway: A Single-Center Quality-Improvement Study

Background Boarding inflates emergency-to-inpatient throughput time. We implemented a change package, pulling bed decisions upstream, disciplining handoffs, and removing a large diagnostic gate in a tertiary emergency department (ED), and evaluated its operational impact. Methodology We conducted a single-center, pre-post, quality-improvement study of adult ED admissions from January to August 2023. The baseline phase included admissions from January to March 2023, and the post-intervention phase included admissions from April to August 2023 after implementation of the Lean redesign on April 1, 2023. The primary endpoint was patient-level total admission cycle time, which was captured electronically from the electronic health record (EHR) and calculated as the number of minutes from admission order to inpatient bed arrival. Value stream mapping was utilized as a complementary process diagnostic tool to illustrate typical pathway lead times, categorize value-added and non-value-added activities, and determine process efficiencies. Map-based step medians were not considered to be directly interchangeable with aggregate patient-level cycle times, but rather as a diagnostic summary. Results Total admission cycle time as reported by EHRs (baseline, N = 217; post-intervention, N = 218) showed a reduction from 390 to 175 minutes (-215 minutes; 55% relative reduction). Non-value-added time fell from 290 to 90 minutes (-200 minutes; -69%) while value-added time saw a more modest change from 100 to 85 minutes (-15%). The process efficiency rose from 25.6% to 48.6% (+23.0 percentage points; ~+90% relative). Process-map results indicated that there was an improvement in the direction, and that three of the most significant sources of non-value-added time were diagnostic waiting, bed coordination, and transfer delays. Conclusions This single-center, pre-post, quality-improvement study found that a Lean redesign of the ED-to-inpatient admission pathway was linked to a clinically meaningful decrease in the admission cycle time and an increase in process efficiency. The results indicate that there may be value in pursuing earlier bed coordination, risk-based diagnostic gating, and standardizing handoffs as targets for future controlled or multisite evaluation, but not causal evidence.