Speed up Queue board loads by dropping sync and gate side effects.

Stop issuing missing tickets and refreshing financial gates on every GET;
eager-load advances, cap board rows, and cache specialty department maps.

Co-authored-by: Cursor <cursoragent@cursor.com>

app/Http/Controllers/Care/QueueController.php

@@ -61,37 +61,32 @@ class QueueController extends Controller
         }
 
         if ($this->queueBridge->isEnabled($organization)) {
-            $syncBranches = $lockToPractitioner
+            // Ticket backfill belongs on check-in / Call next / care:queue-sync-tickets —
-                ? Practitioner::owned($owner)
+            // not on every board GET (can issue up to 100 tickets with provisioner work).
-                    ->whereIn('id', $practitionerScope ?: [0])
-                    ->pluck('branch_id')
-                    ->map(fn ($id) => (int) $id)
-                    ->unique()
-                    ->filter()
-                    ->values()
-                    ->all()
-                : array_filter([$branchId]);
-
-            foreach ($syncBranches as $syncBranchId) {
-                $this->queueBridge->syncMissingAppointmentTickets($organization, $syncBranchId, 100);
-            }
-
             if ($branchId > 0) {
                 $queueIntegration = $this->queueBridge->listMeta($organization, $queueContext, $branchId);
-            } elseif ($syncBranches !== []) {
+            } elseif ($lockToPractitioner && $practitionerScope) {
+                $firstBranch = (int) Practitioner::owned($owner)
+                    ->whereIn('id', $practitionerScope)
+                    ->value('branch_id');
+                if ($firstBranch > 0) {
                     $queueIntegration = $this->queueBridge->listMeta(
                         $organization,
                         $queueContext,
-                    (int) $syncBranches[0],
+                        $firstBranch,
                     );
                 }
             }
+        }
+
+        $boardLimit = AppointmentService::QUEUE_BOARD_LIMIT;
 
         if ($lockToPractitioner) {
             $queue = $this->appointments->queueForPractitioners(
                 $owner,
                 $practitionerScope ?? [],
                 $branchId > 0 ? $branchId : null,
+                $boardLimit,
             );
             $inConsultation = Appointment::owned($owner)
                 ->where('organization_id', $organization->id)
@@ -99,10 +94,11 @@ class QueueController extends Controller
                 ->whereIn('practitioner_id', $practitionerScope ?: [0])
                 ->with(['patient', 'practitioner', 'consultation', 'visit', 'organization'])
                 ->orderBy('started_at')
+                ->limit($boardLimit)
                 ->get();
         } else {
             $queue = $branchId
-                ? $this->appointments->queue($owner, $branchId, $practitionerId)
+                ? $this->appointments->queue($owner, $branchId, $practitionerId, true, null, $boardLimit)
                 : collect();
             $inConsultation = Appointment::owned($owner)
                 ->where('organization_id', $organization->id)
@@ -111,6 +107,7 @@ class QueueController extends Controller
                 ->when($practitionerId, fn ($q) => $q->where('practitioner_id', $practitionerId))
                 ->with(['patient', 'practitioner', 'consultation', 'visit', 'organization'])
                 ->orderBy('started_at')
+                ->limit($boardLimit)
                 ->get();
         }
 
@@ -126,6 +123,36 @@ class QueueController extends Controller
             $todayQuery->where('branch_id', $branchId);
         }
 
+        $waitingCountQuery = Appointment::owned($owner)
+            ->where('organization_id', $organization->id)
+            ->whereIn('status', [Appointment::STATUS_WAITING, Appointment::STATUS_CHECKED_IN]);
+        if ($lockToPractitioner) {
+            $waitingCountQuery->whereIn('practitioner_id', $practitionerScope ?: [0]);
+            if ($branchId > 0) {
+                $waitingCountQuery->where('branch_id', $branchId);
+            }
+        } elseif ($branchId) {
+            $waitingCountQuery->where('branch_id', $branchId);
+            if ($practitionerId) {
+                $waitingCountQuery->where(function ($q) use ($practitionerId) {
+                    $q->where('practitioner_id', $practitionerId)->orWhereNull('practitioner_id');
+                });
+            }
+        } else {
+            $waitingCountQuery->whereRaw('1 = 0');
+        }
+
+        $inCareCountQuery = Appointment::owned($owner)
+            ->where('organization_id', $organization->id)
+            ->where('status', Appointment::STATUS_IN_CONSULTATION);
+        if ($lockToPractitioner) {
+            $inCareCountQuery->whereIn('practitioner_id', $practitionerScope ?: [0]);
+        } else {
+            $inCareCountQuery
+                ->when($branchId, fn ($q) => $q->where('branch_id', $branchId))
+                ->when($practitionerId, fn ($q) => $q->where('practitioner_id', $practitionerId));
+        }
+
         $doneQuery = Appointment::owned($owner)
             ->where('organization_id', $organization->id)
             ->where('status', Appointment::STATUS_COMPLETED)
@@ -145,11 +172,13 @@ class QueueController extends Controller
             ->get();
 
         $heroStats = [
-            'waiting' => $queue->count(),
+            'waiting' => $waitingCountQuery->count(),
-            'in_consultation' => $inConsultation->count(),
+            'in_consultation' => $inCareCountQuery->count(),
             'today' => $todayQuery->count(),
         ];
 
+        $specialtyDepartmentMap = $this->queueBridge->specialtyDepartmentMap($organization);
+
         return view('care.queue.index', [
             'organization' => $organization,
             'branches' => $branches,
@@ -174,6 +203,7 @@ class QueueController extends Controller
             'queueIntegration' => $queueIntegration,
             'queueContext' => $queueContext,
             'specialtyLabel' => $specialtyLabel,
+            'specialtyDepartmentMap' => $specialtyDepartmentMap,
         ]);
     }
 

app/Http/Controllers/Care/SpecialtyModuleController.php

@@ -623,7 +623,7 @@ class SpecialtyModuleController extends Controller
                 $practitionerScope !== null,
                 fn ($q) => $q->whereIn('practitioner_id', $practitionerScope ?: [0]),
             )
-            ->with(['patient', 'practitioner', 'department', 'visit'])
+            ->with(['patient', 'practitioner', 'department', 'visit.currentStageAdvance.stage'])
             ->orderBy('queue_position')
             ->orderBy('checked_in_at')
             ->limit(50)

app/Models/Visit.php

@@ -94,6 +94,22 @@ class Visit extends Model
         return $this->hasMany(VisitStageAdvance::class, 'visit_id');
     }
 
+    /**
+     * Active or blocked advance for the visit's current workflow stage.
+     * Prefer this for eager-loaded queue board filtering (avoids N+1 currentAdvance queries).
+     */
+    public function currentStageAdvance(): HasOne
+    {
+        return $this->hasOne(VisitStageAdvance::class, 'visit_id')
+            ->ofMany(
+                ['id' => 'max'],
+                fn ($query) => $query->whereIn('status', [
+                    VisitStageAdvance::STATUS_ACTIVE,
+                    VisitStageAdvance::STATUS_BLOCKED,
+                ]),
+            );
+    }
+
     public function financialObligations(): HasMany
     {
         return $this->hasMany(FinancialObligation::class, 'visit_id');

app/Services/Care/AppointmentService.php

@@ -83,6 +83,9 @@ class AppointmentService
         return $query->paginate((int) ($filters['per_page'] ?? 20))->withQueryString();
     }
 
+    /** Max waiters / in-care rows rendered on the patient-flow board. */
+    public const QUEUE_BOARD_LIMIT = 50;
+
     /**
      * @param  list<int>|null  $practitionerIds
      * @return Collection<int, Appointment>
@@ -93,20 +96,29 @@ class AppointmentService
         ?int $practitionerId = null,
         bool $includeUnassigned = true,
         ?array $practitionerIds = null,
+        ?int $limit = null,
     ): Collection {
         if ($practitionerIds !== null) {
-            return $this->queueForPractitioners($ownerRef, $practitionerIds, $branchId > 0 ? $branchId : null);
+            return $this->queueForPractitioners(
+                $ownerRef,
+                $practitionerIds,
+                $branchId > 0 ? $branchId : null,
+                $limit,
+            );
         }
 
         $this->repairDuplicateQueuePositions($ownerRef, $branchId);
 
+        $limit = $limit ?? self::QUEUE_BOARD_LIMIT;
+
         $query = Appointment::owned($ownerRef)
             ->where('branch_id', $branchId)
             ->whereIn('status', [Appointment::STATUS_WAITING, Appointment::STATUS_CHECKED_IN])
-            ->with(['patient', 'practitioner', 'visit', 'organization'])
+            ->with($this->queueEagerLoads())
             ->orderBy('queue_position')
             ->orderBy('waiting_at')
-            ->orderBy('checked_in_at');
+            ->orderBy('checked_in_at')
+            ->limit($limit);
 
         if ($practitionerId !== null) {
             $query->where(function (Builder $q) use ($practitionerId, $includeUnassigned) {
@@ -124,7 +136,7 @@ class AppointmentService
                     return true;
                 }
 
-                return $this->workflowGate->canRelease(
+                return $this->workflowGate->isReleasedForDisplay(
                     $organization,
                     $appointment->visit,
                     $this->queueBridge->contextForAppointment($organization, $appointment),
@@ -139,20 +151,27 @@ class AppointmentService
      * @param  list<int>  $practitionerIds
      * @return Collection<int, Appointment>
      */
-    public function queueForPractitioners(string $ownerRef, array $practitionerIds, ?int $branchId = null): Collection
+    public function queueForPractitioners(
-    {
+        string $ownerRef,
+        array $practitionerIds,
+        ?int $branchId = null,
+        ?int $limit = null,
+    ): Collection {
         if ($practitionerIds === []) {
             return new Collection;
         }
 
+        $limit = $limit ?? self::QUEUE_BOARD_LIMIT;
+
         $query = Appointment::owned($ownerRef)
             ->whereIn('practitioner_id', $practitionerIds)
             ->whereIn('status', [Appointment::STATUS_WAITING, Appointment::STATUS_CHECKED_IN])
             ->when($branchId, fn ($q) => $q->where('branch_id', $branchId))
-            ->with(['patient', 'practitioner', 'visit', 'organization'])
+            ->with($this->queueEagerLoads())
             ->orderBy('queue_position')
             ->orderBy('waiting_at')
-            ->orderBy('checked_in_at');
+            ->orderBy('checked_in_at')
+            ->limit($limit);
 
         $practitioners = Practitioner::owned($ownerRef)
             ->whereIn('id', $practitionerIds)
@@ -192,7 +211,7 @@ class AppointmentService
                         return false;
                     }
 
-                    return $this->workflowGate->canRelease(
+                    return $this->workflowGate->isReleasedForDisplay(
                         $organization,
                         $appointment->visit,
                         $context,
@@ -203,6 +222,19 @@ class AppointmentService
         );
     }
 
+    /**
+     * @return list<string|array<string, mixed>>
+     */
+    protected function queueEagerLoads(): array
+    {
+        return [
+            'patient',
+            'practitioner',
+            'organization',
+            'visit.currentStageAdvance.stage',
+        ];
+    }
+
     /**
      * @param  array<string, mixed>  $data
      */
@@ -484,25 +516,33 @@ class AppointmentService
     /**
      * Demo specialty seed used to set every module's waiter to position 1.
      * Repair duplicates in place so the patient queue shows 1..n.
+     * Cheap existence check first so healthy queues skip the full rewrite.
      */
     protected function repairDuplicateQueuePositions(string $ownerRef, int $branchId): void
     {
-        $waiters = Appointment::owned($ownerRef)
+        $base = Appointment::owned($ownerRef)
             ->where('branch_id', $branchId)
-            ->whereIn('status', [Appointment::STATUS_WAITING, Appointment::STATUS_CHECKED_IN])
+            ->whereIn('status', [Appointment::STATUS_WAITING, Appointment::STATUS_CHECKED_IN]);
+
+        $waiterCount = (clone $base)->count();
+        if ($waiterCount < 2) {
+            return;
+        }
+
+        $hasNulls = (clone $base)->whereNull('queue_position')->exists();
+        $distinctPositions = (int) (clone $base)
+            ->whereNotNull('queue_position')
+            ->selectRaw('count(distinct queue_position) as aggregate')
+            ->value('aggregate');
+        if (! $hasNulls && $distinctPositions === $waiterCount) {
+            return;
+        }
+
+        $waiters = (clone $base)
             ->orderByRaw('COALESCE(waiting_at, checked_in_at, scheduled_at) asc')
             ->orderBy('id')
             ->get(['id', 'queue_position']);
 
-        if ($waiters->count() < 2) {
-            return;
-        }
-
-        $positions = $waiters->pluck('queue_position');
-        if ($positions->filter(fn ($p) => $p !== null)->unique()->count() === $waiters->count()) {
-            return;
-        }
-
         foreach ($waiters as $index => $appointment) {
             $position = $index + 1;
             if ((int) $appointment->queue_position === $position) {

app/Services/Care/CareQueueBridge.php

@@ -19,6 +19,9 @@ use Illuminate\Support\Facades\Log;
  */
 class CareQueueBridge
 {
+    /** @var array<int, array<int, string>> organization_id => [department_id => specialty_key] */
+    protected array $specialtyDepartmentMaps = [];
+
     public function __construct(
         protected CareQueueEngine $engine,
         protected CareQueueProvisioner $provisioner,
@@ -49,14 +52,34 @@ class CareQueueBridge
             return CareQueueContexts::CONSULTATION;
         }
 
+        return $this->specialtyDepartmentMap($organization)[$departmentId]
+            ?? CareQueueContexts::CONSULTATION;
+    }
+
+    /**
+     * Department id → specialty module key for this org (request-scoped cache).
+     *
+     * @return array<int, string>
+     */
+    public function specialtyDepartmentMap(Organization $organization): array
+    {
+        $orgId = (int) $organization->id;
+        if (isset($this->specialtyDepartmentMaps[$orgId])) {
+            return $this->specialtyDepartmentMaps[$orgId];
+        }
+
+        $map = [];
         foreach ($this->specialties->enabledKeys($organization) as $key) {
             $deptIds = data_get($organization->settings, "specialty_module_provisioning.{$key}.department_ids", []);
-            if (is_array($deptIds) && in_array($departmentId, array_map('intval', $deptIds), true)) {
+            if (! is_array($deptIds)) {
-                return $key;
+                continue;
+            }
+            foreach ($deptIds as $deptId) {
+                $map[(int) $deptId] = $key;
             }
         }
 
-        return CareQueueContexts::CONSULTATION;
+        return $this->specialtyDepartmentMaps[$orgId] = $map;
     }
 
     public function contextForPractitioner(Organization $organization, ?Practitioner $practitioner): string
@@ -496,7 +519,7 @@ class CareQueueBridge
             ];
         }
 
-        $resources = $this->provisioner->ensure($organization->fresh(), $context, $branchId);
+        $resources = $this->provisioner->ensure($organization, $context, $branchId);
 
         return [
             'enabled' => true,

app/Services/Care/Workflow/WorkflowEngine.php

@@ -64,6 +64,17 @@ class WorkflowEngine
 
     public function currentAdvance(Visit $visit): ?VisitStageAdvance
     {
+        if ($visit->relationLoaded('currentStageAdvance')) {
+            return $visit->currentStageAdvance;
+        }
+
+        if ($visit->relationLoaded('stageAdvances')) {
+            return $visit->stageAdvances
+                ->whereIn('status', [VisitStageAdvance::STATUS_ACTIVE, VisitStageAdvance::STATUS_BLOCKED])
+                ->sortByDesc('id')
+                ->first();
+        }
+
         return VisitStageAdvance::query()
             ->where('visit_id', $visit->id)
             ->whereIn('status', [VisitStageAdvance::STATUS_ACTIVE, VisitStageAdvance::STATUS_BLOCKED])

app/Services/Care/Workflow/WorkflowQueueGate.php

@@ -4,6 +4,7 @@ namespace App\Services\Care\Workflow;
 
 use App\Models\Organization;
 use App\Models\Visit;
+use App\Models\VisitStageAdvance;
 use App\Models\WorkflowStage;
 use App\Services\Care\CareFeatures;
 use App\Services\Care\CareQueueContexts;
@@ -24,6 +25,10 @@ class WorkflowQueueGate
         return $this->features->enabled($organization, CareFeatures::WORKFLOW_ENGINE);
     }
 
+    /**
+     * Mutating gate used when issuing tickets or starting encounters.
+     * May start a workflow or refresh financial gate state.
+     */
     public function canRelease(
         Organization $organization,
         ?Visit $visit,
@@ -36,29 +41,31 @@ class WorkflowQueueGate
         $advance = $this->engine->currentAdvance($visit)
             ? $this->engine->refreshGate($visit)
             : $this->engine->start($visit);
-        $stage = $advance?->stage;
 
-        // An enabled org without a materialized workflow keeps legacy behavior.
+        return $this->evaluateAdvance($organization, $visit, $advance, $queueContext, mutate: true);
-        if ($stage === null) {
+    }
+
+    /**
+     * Read-only gate for waiting-list / board rendering.
+     * Does not start workflows, create obligations, or refresh gate rows.
+     */
+    public function isReleasedForDisplay(
+        Organization $organization,
+        ?Visit $visit,
+        string $queueContext,
+    ): bool {
+        if (! $this->enabled($organization) || $visit === null) {
             return true;
         }
 
-        // Pay-before-service holds belong on the cashier / billing line, not the
+        $advance = $this->engine->currentAdvance($visit);
-        // clinical service queue for the current stage.
+
-        if ($queueContext === CareQueueContexts::BILLING
+        // No materialized advance yet — keep legacy visibility (do not start on GET).
-            && $this->isAwaitingFinancialGate($organization, $visit, $stage)) {
+        if ($advance === null) {
             return true;
         }
 
-        if (! $this->contextsMatch($stage->queue_context, $stage->type, $queueContext)) {
+        return $this->evaluateAdvance($organization, $visit, $advance, $queueContext, mutate: false);
-            return false;
-        }
-
-        if (! $this->features->enabled($organization, CareFeatures::FINANCIAL_GATES)) {
-            return true;
-        }
-
-        return $this->engine->isQueueReleasable($visit);
     }
 
     /**
@@ -81,6 +88,46 @@ class WorkflowQueueGate
         return ! $this->engine->isQueueReleasable($visit);
     }
 
+    protected function evaluateAdvance(
+        Organization $organization,
+        Visit $visit,
+        ?VisitStageAdvance $advance,
+        string $queueContext,
+        bool $mutate,
+    ): bool {
+        $stage = $advance?->stage;
+
+        // An enabled org without a materialized workflow keeps legacy behavior.
+        if ($stage === null) {
+            return true;
+        }
+
+        // Pay-before-service holds belong on the cashier / billing line, not the
+        // clinical service queue for the current stage.
+        if ($queueContext === CareQueueContexts::BILLING) {
+            if ($mutate
+                ? $this->isAwaitingFinancialGate($organization, $visit, $stage)
+                : ($advance->isBlocked() && $stage->gatesBeforeService())) {
+                return true;
+            }
+        }
+
+        if (! $this->contextsMatch($stage->queue_context, $stage->type, $queueContext)) {
+            return false;
+        }
+
+        if (! $this->features->enabled($organization, CareFeatures::FINANCIAL_GATES)) {
+            return true;
+        }
+
+        // Display path trusts advance status (payment clear paths refresh the gate).
+        if (! $mutate) {
+            return ! $advance->isBlocked();
+        }
+
+        return $this->engine->isQueueReleasable($visit);
+    }
+
     protected function contextsMatch(?string $stageContext, string $stageType, string $queueContext): bool
     {
         if ($stageContext === $queueContext) {

resources/views/care/queue/index.blade.php

@@ -1,6 +1,6 @@
 @php
     $specialtyLabel = $specialtyLabel ?? null;
-    $queueBridge = app(\App\Services\Care\CareQueueBridge::class);
+    $specialtyDepartmentMap = $specialtyDepartmentMap ?? [];
 @endphp
 <x-app-layout title="Queue">
     <div class="space-y-6">
@@ -40,17 +40,15 @@
             'queueCallNextParams' => array_filter(['practitioner_id' => $practitionerId]),
             'startRouteName' => 'care.queue.start',
             'inCareLabel' => $specialtyLabel ? 'In care' : 'In consultation',
-            'openInCareUrl' => function ($appointment) use ($queueBridge) {
+            'openInCareUrl' => function ($appointment) use ($specialtyDepartmentMap) {
-                $organization = $appointment->organization;
+                $deptId = (int) ($appointment->department_id ?? 0);
-                if ($organization && $appointment->visit) {
+                $module = $deptId > 0 ? ($specialtyDepartmentMap[$deptId] ?? null) : null;
-                    $context = $queueBridge->contextForAppointment($organization, $appointment);
+                if ($module && $appointment->visit) {
-                    if ($context !== \App\Services\Care\CareQueueContexts::CONSULTATION) {
                     return route('care.specialty.workspace', [
-                            'module' => $context,
+                        'module' => $module,
                         'visit' => $appointment->visit,
                     ]);
                 }
-                }
 
                 return $appointment->consultation
                     ? route('care.consultations.show', $appointment->consultation)

tests/Feature/CareQueueBoardPerformanceTest.php

@@ -0,0 +1,263 @@
+<?php
+
+namespace Tests\Feature;
+
+use App\Http\Middleware\EnsurePlatformSession;
+use App\Models\Appointment;
+use App\Models\Branch;
+use App\Models\FacilityWorkflow;
+use App\Models\Member;
+use App\Models\Organization;
+use App\Models\Patient;
+use App\Models\User;
+use App\Models\Visit;
+use App\Models\VisitStageAdvance;
+use App\Models\WorkflowStage;
+use App\Services\Care\AppointmentService;
+use App\Services\Care\CareFeatures;
+use App\Services\Care\CareQueueContexts;
+use App\Services\Care\Workflow\WorkflowQueueGate;
+use Illuminate\Foundation\Testing\RefreshDatabase;
+use Illuminate\Support\Facades\DB;
+use Tests\TestCase;
+
+class CareQueueBoardPerformanceTest extends TestCase
+{
+    use RefreshDatabase;
+
+    protected User $owner;
+
+    protected Organization $organization;
+
+    protected Branch $branch;
+
+    protected function setUp(): void
+    {
+        parent::setUp();
+        $this->withoutMiddleware(EnsurePlatformSession::class);
+
+        $this->owner = User::create([
+            'public_id' => 'queue-perf-owner',
+            'name' => 'Owner',
+            'email' => 'queue-perf@example.com',
+        ]);
+
+        $this->organization = Organization::create([
+            'owner_ref' => $this->owner->public_id,
+            'name' => 'Perf Clinic',
+            'slug' => 'perf-clinic',
+            'settings' => [
+                'onboarded' => true,
+                'facility_type' => 'clinic',
+                'plan' => 'pro',
+                'plan_expires_at' => now()->addMonth()->toIso8601String(),
+                'queue_integration_enabled' => true,
+                'rollout' => [
+                    CareFeatures::WORKFLOW_ENGINE => true,
+                    CareFeatures::FINANCIAL_GATES => true,
+                ],
+            ],
+        ]);
+
+        Member::create([
+            'owner_ref' => $this->owner->public_id,
+            'organization_id' => $this->organization->id,
+            'user_ref' => $this->owner->public_id,
+            'role' => 'receptionist',
+        ]);
+
+        $this->branch = Branch::create([
+            'owner_ref' => $this->owner->public_id,
+            'organization_id' => $this->organization->id,
+            'name' => 'Main',
+            'is_active' => true,
+        ]);
+    }
+
+    public function test_queue_index_does_not_backfill_tickets_or_start_workflows(): void
+    {
+        $workflow = FacilityWorkflow::create([
+            'owner_ref' => $this->owner->public_id,
+            'organization_id' => $this->organization->id,
+            'branch_id' => $this->branch->id,
+            'name' => 'Default',
+            'is_active' => true,
+        ]);
+        WorkflowStage::create([
+            'owner_ref' => $this->owner->public_id,
+            'workflow_id' => $workflow->id,
+            'code' => 'consultation',
+            'name' => 'Consultation',
+            'type' => 'consultation',
+            'queue_context' => CareQueueContexts::CONSULTATION,
+            'sort_order' => 1,
+            'requires_payment' => false,
+        ]);
+
+        $seedWaiters = function (int $count, int $offset = 0): void {
+            for ($i = 0; $i < $count; $i++) {
+                $n = $offset + $i;
+                $patient = Patient::create([
+                    'owner_ref' => $this->owner->public_id,
+                    'organization_id' => $this->organization->id,
+                    'branch_id' => $this->branch->id,
+                    'patient_number' => 'P-PERF-'.$n,
+                    'first_name' => 'Pat',
+                    'last_name' => (string) $n,
+                ]);
+                $visit = Visit::create([
+                    'owner_ref' => $this->owner->public_id,
+                    'organization_id' => $this->organization->id,
+                    'branch_id' => $this->branch->id,
+                    'patient_id' => $patient->id,
+                    'status' => Visit::STATUS_OPEN,
+                    'checked_in_at' => now(),
+                ]);
+                Appointment::create([
+                    'owner_ref' => $this->owner->public_id,
+                    'organization_id' => $this->organization->id,
+                    'branch_id' => $this->branch->id,
+                    'patient_id' => $patient->id,
+                    'visit_id' => $visit->id,
+                    'type' => Appointment::TYPE_WALK_IN,
+                    'status' => Appointment::STATUS_WAITING,
+                    'scheduled_at' => now(),
+                    'waiting_at' => now()->subMinutes(100 - $n),
+                    'queue_position' => $n + 1,
+                ]);
+            }
+        };
+
+        $seedWaiters(5);
+        DB::flushQueryLog();
+        DB::enableQueryLog();
+        $this->actingAs($this->owner)
+            ->get(route('care.queue.index', ['branch_id' => $this->branch->id]))
+            ->assertOk();
+        $queriesWith5 = count(DB::getQueryLog());
+        DB::disableQueryLog();
+
+        $seedWaiters(20, 5);
+        DB::flushQueryLog();
+        DB::enableQueryLog();
+        $this->actingAs($this->owner)
+            ->get(route('care.queue.index', ['branch_id' => $this->branch->id]))
+            ->assertOk()
+            ->assertSee('Patient flow');
+        $log = collect(DB::getQueryLog());
+        DB::disableQueryLog();
+        $queriesWith25 = $log->count();
+
+        $this->assertSame(0, Appointment::query()->whereNotNull('queue_ticket_uuid')->where('queue_ticket_uuid', '!=', '')->count());
+        $this->assertSame(0, VisitStageAdvance::query()->count(), 'Board GET must not start workflows');
+
+        // Adding 20 waiters must not add ~N queries (gate refresh / ticket sync / context loops).
+        $delta = $queriesWith25 - $queriesWith5;
+        $this->assertLessThan(
+            25,
+            $delta,
+            "Query delta for +20 waiters should be small (eager loads), got {$delta} (5={$queriesWith5}, 25={$queriesWith25})",
+        );
+
+        $advanceLookups = $log->filter(
+            fn ($q) => str_contains(strtolower($q['query']), 'care_visit_stage_advances'),
+        )->count();
+        $this->assertLessThanOrEqual(
+            3,
+            $advanceLookups,
+            "visit_stage_advances lookups should be eager-loaded, got {$advanceLookups}",
+        );
+    }
+
+    public function test_queue_board_caps_waiting_list_size(): void
+    {
+        $limit = AppointmentService::QUEUE_BOARD_LIMIT;
+
+        for ($i = 0; $i < $limit + 15; $i++) {
+            $patient = Patient::create([
+                'owner_ref' => $this->owner->public_id,
+                'organization_id' => $this->organization->id,
+                'branch_id' => $this->branch->id,
+                'patient_number' => 'P-CAP-'.$i,
+                'first_name' => 'Cap',
+                'last_name' => (string) $i,
+            ]);
+            Appointment::create([
+                'owner_ref' => $this->owner->public_id,
+                'organization_id' => $this->organization->id,
+                'branch_id' => $this->branch->id,
+                'patient_id' => $patient->id,
+                'type' => Appointment::TYPE_WALK_IN,
+                'status' => Appointment::STATUS_WAITING,
+                'scheduled_at' => now(),
+                'waiting_at' => now()->subMinutes($limit + 15 - $i),
+                'queue_position' => $i + 1,
+            ]);
+        }
+
+        $queue = app(AppointmentService::class)->queue(
+            $this->owner->public_id,
+            $this->branch->id,
+        );
+
+        $this->assertCount($limit, $queue);
+        $this->assertSame(1, (int) $queue->first()->queue_position);
+    }
+
+    public function test_display_gate_hides_blocked_visits_without_refresh(): void
+    {
+        $workflow = FacilityWorkflow::create([
+            'owner_ref' => $this->owner->public_id,
+            'organization_id' => $this->organization->id,
+            'branch_id' => $this->branch->id,
+            'name' => 'Gated',
+            'is_active' => true,
+        ]);
+        $stage = WorkflowStage::create([
+            'owner_ref' => $this->owner->public_id,
+            'workflow_id' => $workflow->id,
+            'code' => 'consultation',
+            'name' => 'Consultation',
+            'type' => 'consultation',
+            'queue_context' => CareQueueContexts::CONSULTATION,
+            'sort_order' => 1,
+            'requires_payment' => true,
+            'payment_timing' => 'before',
+            'default_amount_minor' => 1000,
+        ]);
+
+        $patient = Patient::create([
+            'owner_ref' => $this->owner->public_id,
+            'organization_id' => $this->organization->id,
+            'branch_id' => $this->branch->id,
+            'patient_number' => 'P-GATE',
+            'first_name' => 'Blocked',
+            'last_name' => 'Patient',
+        ]);
+        $visit = Visit::create([
+            'owner_ref' => $this->owner->public_id,
+            'organization_id' => $this->organization->id,
+            'branch_id' => $this->branch->id,
+            'patient_id' => $patient->id,
+            'status' => Visit::STATUS_OPEN,
+            'checked_in_at' => now(),
+        ]);
+        VisitStageAdvance::create([
+            'owner_ref' => $this->owner->public_id,
+            'visit_id' => $visit->id,
+            'workflow_id' => $workflow->id,
+            'workflow_stage_id' => $stage->id,
+            'stage_code' => 'consultation',
+            'status' => VisitStageAdvance::STATUS_BLOCKED,
+            'blocked_reason' => 'awaiting_payment',
+            'entered_at' => now(),
+        ]);
+
+        $gate = app(WorkflowQueueGate::class);
+        $this->assertFalse($gate->isReleasedForDisplay(
+            $this->organization,
+            $visit->fresh('currentStageAdvance.stage'),
+            CareQueueContexts::CONSULTATION,
+        ));
+    }
+}

tests/Feature/CareQueueBridgeTest.php

@@ -367,12 +367,20 @@ class CareQueueBridgeTest extends TestCase
             'reason' => 'Toothache',
         ]);
 
+        // Board GET must remain read-only; ticket backfill is explicit (Call next / artisan).
         $this->actingAs($this->owner)
             ->get(route('care.queue.index', ['branch_id' => $this->branch->id]))
             ->assertOk()
             ->assertSee('Toothache');
 
         $appointment = Appointment::query()->where('patient_id', $this->patient->id)->first();
+        $this->assertNull($appointment?->queue_ticket_uuid);
+
+        $issued = app(\App\Services\Care\CareQueueBridge::class)
+            ->syncMissingAppointmentTickets($this->organization->fresh(), (int) $this->branch->id, 10);
+        $this->assertSame(1, $issued);
+
+        $appointment = $appointment->fresh();
         $this->assertNotNull($appointment?->queue_ticket_uuid);
         $this->assertStringStartsWith('DEN', (string) $appointment->queue_ticket_number);
         $this->assertDatabaseHas('care_service_queues', [