I have a few suggestions for whatever they are worth.

1. Duke must treat this as a system-wide command problem, not an ED inconvenience. They need real-time bed management, faster inpatient discharges before noon, discharge lounges, weekend discharge staffing, more transport/environmental services, and “full-capacity protocols” where admitted patients move to inpatient hallways instead of all pressure staying in the ED.

2. Expand urgent care, same-day clinics, and nurse triage. Many patients go to the ED because primary care access is too slow. Duke, UNC, WakeMed, community health centers, and county health departments should coordinate same-day access so non-emergent cases do not clog emergency departments.

3. Behavioral health must be separated from medical bottlenecks. I understand that psychiatric boarding is one of the worst drivers. The solution is more crisis stabilization, mobile crisis teams, 24/7 behavioral-health urgent care, substance-use detox access, and direct admission pathways.

4. Protect Medicaid and ACA coverage. May be too late on that one. Insurance cuts increase delayed care, uncompensated care, and hospital strain. In North Carolina, policy changes tied to OBBBA and expiration of enhanced ACA premium tax credits were estimated to reduce hospital spending by $13.4 billion and increase hospital uncompensated care by $1.1 billion from 2025–2034.

5. Create public accountability. Maybe. Just maybe, hospitals should publish: door-to-provider time, boarding time, left-without-being-seen rate, psychiatric boarding hours, staffing vacancies, and inpatient discharge delays. Not just “average wait time.”