Several years ago, Boston-based Massachusetts General Hospital recognized it was facing a growing challenge with emergency department boarding, particularly among general medicine patients. Like many hospitals, MGH had an ED-managed observation unit for patients requiring short-term care, typically under 24 hours. But the hospital increasingly struggled with that setup and it began to rethink short-stay care, which ultimately led to the creation of a clinical decision-making unit.

“We had a 31-bed unit managed by the emergency department, but over the years, it went beyond that functionality,” said Peter Dunn, MD, senior vice president of hospital operations. “It became more of an overflow unit, and the length of stay was fairly extraordinary. It was clear that about 40% of the patients in the ED observation unit qualified for inpatient-level care — not necessarily a long length of care, but still inpatient-level care. Yet, they were being placed in the observation unit.”

To address this issue, the hospital took advantage of a newly available clinical space to launch a new model of short-stay care. This allowed MGH to open 19 unlicensed beds adjacent to the emergency department — a significant shift, since the existing observation unit was located on the 12th floor while the ED was on the first.

“Eventually, we decided that co-locating the ED observation unit to truly serve just ED observation — within that less-than-24-hour window — would be the best use of the new space,” Dr. Dunn told Becker’s. “Then we considered what to do with the 31-bed unit. We realized that if the hospital medicine team took care of the medicine patients — who made up the majority of those meeting inpatient criteria — we could create a short-stay unit for medicine patients. These were patients either in the ED observation unit or occupying licensed inpatient beds that we needed for patients currently boarding in the emergency department.”

MGH had already seen success co-locating postoperative patients in short-stay spaces, particularly in perioperative and procedural areas, so the team built on that experience.

To predict which medicine patients would require a short stay, MGH had previously established an operations research team in collaboration with MIT Sloan School of Management in Cambridge, Mass. Using operations research models, they examined historical patient data to identify the best-suited candidates for the new unit.

The model served as an early guide, but operationalizing the CDU required an 18-month planning effort with multiple iterations, Dr. Dunn said.

“By mid-2024, we coalesced around the idea of a short-stay medical service, staffed by hospitalists — physicians and advanced practice providers — a dedicated nursing staff, and enhanced case management,” he added. “A lot of the challenges in efficient care pathways aren’t strictly clinical; they involve broader system navigation. So case management was a key component. We also ensured that other departments — physical therapy, occupational therapy, and others — could prioritize short-stay patients without deprioritizing others.”

The CDU opened Feb. 4 and gradually scaled up to full use of its 31 beds by April.

Nine months in, the unit is helping MGH reduce emergency department boarding times. Within the first six months, the hospital saw a six-hour drop in ED boarding time for general medicine patients — from 19 hours to 13 hours. Among patients transferring to the CDU, boarding time dropped to 11 hours — a 42% reduction.

CDU patients stay an average of 52 hours. About 70% are discharged home or to their referring hospital, while 30% transition to inpatient care.

Dr. Dunn emphasized that these results were driven by strategic structural changes and team alignment.

“ED observation targets have always been 80/20, with lower-acuity patients and stays under 24 hours,” he explained. “There are many ED algorithms to support those goals. Now that our 19-bed ED observation unit is dedicated to that purpose, they’re hitting those exact targets.

“Previously, the unit combined short-stay and ED observation patients, and wasn’t effectively meeting the needs of either group. Separating them has improved performance. We also looked at the length of stay for long-stay patients in the old ED observation unit, reviewed their trajectories, and used prior experience co-locating short-stay patients in procedural or perioperative areas.”

One of the key hurdles was generating buy-in across departments. Dr. Dunn said not all groups had seen the benefits of co-location in past models.

“Medicine patients are more complex than surgical ones, so that added another layer,” he said. “We used predictive models from our healthcare systems engineering collaboration with MIT, but it took time to get everyone aligned.”

Ultimately, he said, teams agreed on the urgency of reducing ED boarding and committed to the CDU model.

“We agreed to try this approach, measure its performance and adjust if needed,” said Dr. Dunn, adding that an oversight committee was created. “If it didn’t work, we’d regroup. But it has worked. There’s now energy and enthusiasm for trying similar efforts — novel ways to tackle capacity issues.”

Beyond the metrics, Dr. Dunn said the CDU has delivered less visible but important workforce benefits. For example, several clinicians have gravitated toward working in the unit due to its distinct focus and workflow.

He also highlighted the benefit of co-location. “We weren’t sure which nursing group would be the best fit initially,” he said. “The ED nurses had staffed the prior ED observation unit, but many patients were inpatient-level. We started with a blend of ED and inpatient nurses. Over time, the inpatient nurses expressed a preference for this unit, and it has become a desirable place to work. It’s a unique care environment — different from both ED and traditional inpatient care.”

His advice for other hospitals: Don’t default to traditional capacity models.

“We need to try new models. It’s not easy, especially in academic medical centers,” he said. “But if you bring the right team together and support the effort with analytics, it can be powerful.”

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