Process-first relief of emergency department overcrowding: a before–after analysis of time-to-decision and boarding in a regional center

Targeted pathway-level process improvements, especially those that shorten boarding, substantially reduced ED LOS and relieved overcrowding among admitted highacuity patients. A boarding-focused, hospital-wide approach is an operationally transferable framework for institutions that cannot implement composite crowding indices owing to data limitations although attribution to specific components requires more granular study designs.