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inspiring talk from @drdebhoury.bsky.social at #ACEP26

audience member asks about potential hope in partnering with MAHA to advance public health: @drdebhoury.bsky.social : the MAHA *people* are generally reasonable (<10% are antivax) but the MAHA leaders are conflicted (selling supplements etc) or lying about data (RFKjr) [para] #ACEP26

@arjunvenkatesh.bsky.social on all things boarding- why the ED is busy it’s hospital capacity (also related to nursing home & hospital nursing staffing) #ACEP26

ED crowding / boarding results from hospital o & health system dysfunction and lack of capacity (flow) it is NOT low acuity patients ED wait times have functionally replaced the Ottawa ankle rule @arjunvenkatesh.bsky.social #ACEP26

all sorts of factors in ED boarding and outcomes @arjunvenkatesh.bsky.social #ACEP26

ambulance diversion doesn’t help ED boarding, hurts patients physician in triage: some minor improvements with low acuity patients, LWBS but *worse* boarding @arjunvenkatesh.bsky.social #ACEP26

split flow helps patients get seen but doesn’t help boarding hallway care gets patients seen but with worse care, worse boarding @arjunvenkatesh.bsky.social #ACEP26

building more ED spaces doesn’t help ED LOS flow smoothly, ie surgical schedule smoothing, is great if you can convince surgeons to operate on Fridays / weekends, and the infrastructure for it (eg more transporters on weekends) @arjunvenkatesh.bsky.social #ACEP26

if you use ED obs really well (avoiding inpatient admissions) they can help boarding in practice it can be a lot of hospital-based outpatient care (eg specialty consults, imaging) that could be outpatient if the outpatient system worked @arjunvenkatesh.bsky.social #ACEP26

inter campus load leveling can work (Yale’s are only a mile apart) but patients need to know they are getting the same level of care much easier to convince patients to be transferred to the other site IF the patient had boarded in the ED before @arjunvenkatesh.bsky.social #ACEP26

inpatient hallway boarding can work - the secret is 1/4 of upstairs hallway patients magically get a bed faster when the patient is already there but hard to implement until it’s too late, already way above optimal occupancy @arjunvenkatesh.bsky.social #ACEP26

inpatient docs taking care of boarders in the ED does help LOS & boarding @arjunvenkatesh.bsky.social #ACEP26

ECAT: new CMS boarding quality measure failing any one of these is a penalty @arjunvenkatesh.bsky.social #ACEP26

EVAT reporting in 2027 is voluntary, tied to public reporting in 2028 and goes into star ratings (and probably payment) @arjunvenkatesh.bsky.social #ACEP26

good chance hospitals are going to fail ECAT on ~35% of patients broken into 4 scores: adults w/wo mental health condition, and kids w/wo mental health conditions; adult nonmental health is the key category the ED can work on @arjunvenkatesh.bsky.social #ACEP26

hospitals will likely try for quick fixes but quickly learn that it’s all the boarding submeasure and it’s not just an ED problem @arjunvenkatesh.bsky.social #ACEP26

Audience q: why aren’t hospitals building more beds? expensive to build hospital beds (both due to regs and fancy foyers etc), and focus on outpatient care ($) which means lack of focus on declining inpatient reimbursement @arjunvenkatesh.bsky.social #ACEP26

we think of hallway patients as simple & fast but they’re really the same as average ED patients, eg 60yo w abd pain needing a CT @arjunvenkatesh.bsky.social #ACEP26

great anecdote from @arjunvenkatesh.bsky.social : had a resident lay in a hospital bed to see what it’s like. they lasted 2 min. being a hallway patient is a bad experience #ACEP26

a lot of high level stats can be misleading, hide heterogeneity eg some hospitals are expanding but closing in the areas, beds per pop is flat but maldistributed (“lying with averages”) @arjunvenkatesh.bsky.social #ACEP26