CLINICAL RESEARCH STUDY

High Hospital Occupancy Is Associated with Increased

Risk for Patients Boarding in the Emergency Department
Jian-Cang Zhou, MD,a Kong-Han Pan, MD,a Dao-Yang Zhou, MD,a San-Wei Zheng, MSc,b Jian-Qing Zhu, RN,c
Qiu-Ping Xu, MD,a Chang-Liang Wang, MSca
a
Department of Critical Care Medicine, bDepartment of Biomedical Informatics, and cDepartment of Orthopedics, Sir Run Run Shaw
Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.

ABSTRACT
BACKGROUND: Boarding admitted patients in the emergency department due to high hospital occupancy
is a worldwide problem. However, whether or not emergency department-boarded patients managed by
emergency department providers subjects them to increased serious complications needs further
clarification.
METHODS: A multivariate logistic regression analysis was used to examine the relationship of patients age,
sex, arrival hours, diagnostic category, triage category, daily emergency department visits, and daily
hospital occupancy to the occurrence of serious complications within 24 hours for 20,276 emergency
admissions in a 4-year period.
RESULTS: A vast majority of study days (86.5%) saw very high occupancy 90%. Serious complications
incidence was 13.62 per 1000 patient days when hospital occupancy was 90%, and it increased
significantly to 17.10 and 22.52 per 1000 patient days for occupancy at 90%-95% and 95%, respectively.
In the multivariate analysis, significant risk factors for serious complications included daily occupancy
95% (adjusted odds ratio [OR] 1.73; 95% confidence interval [CI], 1.26-2.39), triage category (adjusted
OR 0.20; 95% CI, 0.17-0.24), and specific diagnoses (injury and poisoning [adjusted OR 1.62; 95% CI,
1.22-2.84], respiratory [adjusted OR 2.48; 95% CI, 1.37-4.49], and circulatory [adjusted OR 3.24; 95% CI,
1.80-5.80]).
CONCLUSION: High hospital occupancy was associated with an increased incidence of serious complications within 24 hours for patients admitted but still boarded in the emergency department and managed by
emergency department providers.
2012 Elsevier Inc. All rights reserved. The American Journal of Medicine (2012) 125, 416.e1-416.e7
KEYWORDS: Complication; Crowding; Emergency department

Emergency department crowding is a worldwide problem

affecting many hospitals,1 and it has been associated with
longer waits to be seen, delays in testing and critical treatments, and lower patient satisfaction.2,3 A 2006 report by
the Institute of Medicine notes that bottlenecks in output,
Funding: This study was partially supported by the Medical Scientific
Research Foundation of Zhejiang Province, China (No.2010KYA109). The
funding source played no role in the design, conduct, or reporting of this
study.
Conflict of Interest: None.
Authorship: All authors had access to the data and participated in the
preparation of the manuscript.
Requests for reprints should be addressed to Kong-Han Pan, MD,
Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, Zhejiang, China
E-mail address: pankonghan@medmail.com.cn

0002-9343/$ -see front matter 2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjmed.2011.07.030

such as the inability to transfer admitted patients to inpatient

beds due to high hospital occupancy, is the leading cause of
crowding.4 Therefore, patient flow inefficiency is the constraint factor for emergency department throughput.5 As a
result, boarders occupy emergency department beds, consume emergency department resources, reduce the capacity
for new patients, aggravate crowding, and precipitate a
vicious cycle.6
In some settings, emergency department physicians are
challenged with the responsibility of both caring for boarders and treating new patients. In practice, this means emergency department boarders are in competition with new
acute patients who require emergency care. Because emergency physicians are usually distracted by the flow of new
patients, they often provide insufficient attention to board-

416.e2

The American Journal of Medicine, Vol 125, No 4, April 2012

Although on occasion, patients may be boarded in emerers. An Australian study demonstrated that the relative risk
gency department corridors for short periods during crowdof mortality at 10 days was 1.34 when comparing crowded
ing, the hospital does not permit patients to be boarded in
versus noncrowded shifts.7 Therefore, the likelihood that
corridors or in inpatient hallways when it is at full capacity.
serious complications occur more often for patients boardHence, in order to maintain high occupancy and maxiing in emergency departments awaiting inpatient beds durmize revenue, patients can be
ing high hospital occupancy is an
admitted to any vacant ward deidea with intuitive appeal, yet few
spite most departments having a
empirical data are available about
CLINICAL SIGNIFICANCE
home ward, where staff is expethis. We hypothesized that emerrienced in the relevant specialty.
gency department-boarded patients
The study revealed that high hospital
Every patient in the emergency
managed by emergency department
occupancy was associated with indepartment undergoes initial triproviders were subjected to a higher
creased serious complications for paage by a senior emergency nurse
risk of serious, sometimes lifetients admitted but still boarded in the
according to the Emergency Sethreatening complications. We
emergency department and managed by
verity Index triage algorithm.9 Besought to answer this question by
emergency
department
providers.
examining the association between
cause SRRSH does not have an
the daily hospital occupancy and
emergency department-based ob A patient-centered care model, such as
serious complication rates within
servation unit, all emergency visallowing flexible assignment of service
the 24 hours after admission reits are either discharged or admitlocation and earlier implementation of
quest for all emergency admisted to inpatient wards. Generally,
therapeutic interventions, might be
sions in a 4-year period.
appropriate specialty and emerhelpful to enhance care quality for pagency department physicians joitients boarding in the emergency
ntly determine whether the paMETHODS
department.
tient should be admitted. For those
patients, on occasion, who no speStudy Design and Setting
cialist wants to accept, the emerThis investigation was based on a
gency
department
attending
physician is empowered by the
historical cohort design that included all emergency admishospital
to
appoint
a
relatively
appropriate specialist to
sions to Sir Run Run Shaw Hospital (SRRSH), an urban,
admit.
Because
inpatient
bed
access
block (defined as
800-bed major tertiary teaching hospital in Hangzhou,
patients
requiring
emergency
hospital
admission
and who
China, from January 1, 2006 to December 31, 2009. Howspend
more
than
8
hours
within
the
emergency
department
ever, those patients with a signed Not for Resuscitation
due to the lack of inpatient bed)10 is common, emergency
directive were excluded. The study was approved by the
department providers are required to care for not only new
institutional review board of SRRSH without the need for a
patients, but also boarded patients.
consent form. Since its opening in 1994, SRRSH has been
closely cooperating with Loma Linda University in CaliforData Sources and Processing
nia. Establishment and development of the Emergency DeThe hospitals information system was queried to identify
partment received great assistance from US physicians.8 In
all patients admitted with the emergency department as the
2006 it became the first public hospital in mainland China to
referral source. Hospital occupancy information was acbe accredited by the Joint Commission International, a USquired from Hospital Census Statistics System. The daily
based, World Health Organization-authorized organization
hospital occupancy was calculated as bed days used divided
for medical quality evaluation. All emergency physicians
by bed days available at midnight once per day. For each
are required to attend formal training programs in the Inemergency admission, the following data elements were
tensive Care Unit (ICU) every 6 months, where they learn
extracted: 1) date and time of registration; 2) triage cateand practice protocols for scenarios like sepsis and patient
gory; 3) date and time of admission request; 4) date and
evaluation. The hospital serves a population of nearly 2
time of transfer to inpatient ward; 5) disposition location; 6)
million and receives an average 6000-8000 emergency visdemographic characteristics (age, sex); 7) primary involved
its monthly. Considering the immature community medical
system and primary diagnostic category; 8) daily emergency
infrastructure, Chinese patients would prefer tertiary teachdepartment visits. Boarding hours were calculated as the
ing hospitals rather than family or community doctors, even
difference between time of admission request and time of
for minor problems. Therefore, although many Chinese
the patient departure from the emergency department.
emergency departments are very busy, generally, the averEmergency department length of stay (ED LOS) was calage admission rate is markedly lower than emergency deculated as the difference between the time of registration
partments in developed countries. At SRRSH, approxiand time of the patient departure from the emergency demately 5%-10% of emergency department visits were
partment. Emergency admissions were grouped by primary
admitted within the study period, which accounted for 10%system involved, with reference to the International Classi20% of the total hospital admissions.
fication of Diseases, resulting in 9 diagnostic categories.

Zhou et al

High Hospital Occupancy Poses Risk for ED Boarders

416.e3

Definition and Detection of Serious

Complication
We were interested in the escalation of care due to serious
complications either for the underlying condition or lack of
continued care. In our study, however, we included only
serious complications that were common and identifiable
using chart review. Serious complications included newonset shock (defined as persisting hypotension despite adequate fluid resuscitation or the need for vasoactive drugs),
need for intubation (progressing respiratory failure or concern over airway protection for various reasons necessitating intubation), and death. Patients arriving in the emergency department with, or developing the above serious
complications before the request of admission, were excluded. We did not include unplanned admission to the ICU
because it was difficult to track in charts retrospectively.
We focused on the care within the first 24 hours after
emergency admission requests were made. We used a
2-tiered method for identifying serious complications.11
Two physicians, who were blinded to the occupancy,
reviewed all the medical records independently and identified whether a serious complication may have occurred
using the definitions as previously discussed. The first 50
cases were reviewed jointly, as part of a familiarization
and educative process. The reviewers conferred with a
third attending physician to discuss disagreements and
came to a consensus.

arrival was coded as 1. The covariates were selected into

the model with conditional forward method. Probability for
stepwise were entry 0.05 and removal 0.10. Classification
cutoff was 0.5 and maximum iterations were 20. The model
was applied to obtain odds ratios with 95% CIs before and
after adjustment for potentially confounding factors. The
Hosmer-Lemeshow goodness-of-fit test was used to test the
multivariate logistic regression model fit.

Primary Data Analysis

RESULTS

The Statistical Package for the Social Sciences (Version

11.0, SPSS Inc., Chicago, Ill) was used for the analysis.
Categorical variables were compared by chi-squared analysis. Continuous variables were presented as mean or median and 95% confidence interval (CI). Differences between
various hospital occupancy groups were compared using
one-way analysis of variance. In the case of significant
results, a post hoc multiple comparison analysis was performed using the Bonferroni correction. The relationship
between average monthly hospital occupancy and rate of
serious complications per calendar month was examined,
using a linear regression model. A P .05 was considered
statistically significant.
We constructed a multivariate logistic regression model
using serious complication (0 or 1) as the dependent variable. Independent variables, or predictors, suspected to be
confounded with the likelihood of individual patients experiencing serious complications were assessed in our study.
We identified 3 measurable attributes: individual patient
risk, emergency department volume, and throughput. Individual case complexity included patients age, sex, arrival
hour, triage, and diagnostic category. Our primary measure
of emergency department volume was daily visits. We used
the daily hospital occupancy as the indicator for emergency
department throughput because it was the leading cause to
impact the transfer of boarded patients from the emergency
department to inpatient beds. Male sex and non-office-hour

During the 1461-day study period, there were 250,247

emergency department visits; 20,276 (8.1%) of them were
admitted. A vast majority of study days (86.5%) saw very
high occupancy 90% (Figure 1). With respect to the
diagnostic categories for emergency admissions, digestive
diseases was by far the most common category, followed by
injury and poisoning, neurologic, and respiratory, with infectious and parasitic disease the least common (Figure 2).
We assessed the performance of our chart review method
with inter-rater reliability, which was good (kappa 0.740,
P .001) and showed our chart review method was reliable.
The relationship between average hospital occupancy and
serious complications rates by calendar month was statistically significant (r .412; P .004 by linear regression),
and this is shown in Figure 3.
Emergency admission characteristics, grouped by daily
hospital occupancy, are summarized in Table 1. There were
219 days with daily occupancy 90%, 228 days for 90%95%, and 1014 days for occupancy 95%. Median ED LOS
increased significantly to 9.99 (95% CI, 9.06-10.92) hours
for occupancy 95%. In addition, the percentage of access
block increased steadily, from 4.12% when occupancy was
90% to 6.47% and 14.97% for occupancy 90%-95% and
95%, respectively. The differences of average daily emergency department visits, male sex percentage, age, primary
admission diagnostic categories, percentage of disposition
to ICU, and percentage of triage category 1 and 2 across the

Figure 1 Breakdown of daily midnight hospital bed occupancy during the 4-year period.

416.e4

The American Journal of Medicine, Vol 125, No 4, April 2012

Figure 2 The proportions and absolute numbers of hospital emergency admissions by

their primary admission diagnostic categories between 2006 and 2009.

3 groups were not significant. With respect to hospital

occupancy and serious complications rate, the serious complications was 13.62 per 1000 patient days when hospital
occupancy was 90%, and increased to 17.10 per 1000
patient days for 90%-95% occupancy. The incidence increased substantially to 22.52 per 1000 patient days when
the occupancy was 95%. Among them, the rates of shock
and intubation in the occupancy 95% group were significantly higher than their counterparts of lower occupancy
groups. It is worth noticing that differences in the rate of
death were not statistically significant among various daily
occupancy groups.
Because the incidence of serious complications has a
roughly linear correlation with hospital occupancy (Figure 3),

in order to elucidate the influence of various hospital occupancies on risk of serious complication, we made the daily
hospital occupancy into a categorical variable and coded it
as a dummy variable together with primary admission diagnostic category. Daily hospital occupancy 90% and
digestive category were coded as 0. The result of the
univariate analysis was shown in Table 2 as the odds ratios
and 95% CIs. Emergency triage category, daily hospital
occupancy 95%, and certain diagnoses were associated
with an increased risk of serious complications.
Male sex, age, arrival hours to emergency department,
and daily visits were not significant risk factors and, therefore, they were not included in further analysis. Adjusted
odds ratios of serious complications were derived using a

Figure 3 Average hospital bed occupancy and serious complications rates per calendar
month (r .412; P .004 by linear regression).

Zhou et al
Table 1

High Hospital Occupancy Poses Risk for ED Boarders

416.e5

Characteristics of Emergency Hospital Admissions Grouped by Daily Hospital Occupancy

Daily Hospital Occupancy

Sample Characteristic

Occupancy 90%

Occupancy
90%-95%

Occupancy 95%

Total days
Total emergency hospital
admission
Average daily ED visits: mean,
(95% CI)
Male sex (%)
Age, years: mean, (95% CI)
ED LOS, h; median, (95% CI)
Office hours arrival (8:00 AM5:00 PM) (%)
Primary diagnostic categories
Digestive
Injury & poisoning
Neurologic
Respiratory
Miscellaneous
Circulatory
Neoplasm
Genitourinary
Infectious and parasitic
diseases
Disposition to ICU (%)
Triage urgency (% category 1
and 2)*
Access block (%)*
Serious complications (per
1000 patient days)
Shock
Intubation
Death

219
3304

228
4094

1014
12,878

173.0 (164.7-181.2)

174.0 (167.6-180.5)

166.1 (163.4-168.7)

1.000

.067

.155

2012
53.7
6.73
2138

2393
52.6
6.34
2608

7621
52.7
9.99
8557

.262
.535
1.000
.369

.641
1.000
.001
.001

.350
.364
.004
.060

.844

.286

.572

(60.90%)
(52.5-55.0)
(4.66-8.80)
(64.71%)

1083
497
351
331
279
268
242
181
72

(58.45%)
(51.6-53.7)
(5.24-7.43)
(63.70%)

1373
624
423
400
329
345
265
232
103

(59.18%)
(52.2-53.2)
(9.06-10.92)
(66.45%)

Pa

Pb

Pc

4335
2115
1314
1209
1037
990
912
693
273

716 (21.67%)
852 (25.78%)

922 (22.52%)
1064 (25.99%)

2995 (23.26%)
3528 (27.40%)

.381
.843

.330
.078

.053
.063

136 (4.12%)
45 (13.62)

265 (6.47%)
70 (17.10)

1928 (14.97%)
290 (22.52)

.001
.230

.001
.036

.001
.001

26 (7.87)
15 (4.54)
4 (1.21)

33 (8.06)
30 (7.33)
7 (1.71)

150 (11.65)
123 (9.55)
17 (1.32)

.927
.125
.580

.053
.266
.563

.062
.005
.876

CI confidence interval; ED emergency department; ICU intensive care unit; LOS length of stay; Pa comparison between occupancy 90%
and occupancy 90%-95%, Pb comparison between occupancy 90%-95% and occupancy 95%, Pc comparison between occupancy 90% and
occupancy 95%.
* Triage category on the Emergency Severity Index, a 5-level triage system, where 1 represents the sickest or most urgent cases; access block: defined
as patients requiring emergency hospital admission who spend more than 8 hours within the ED due to the lack of inpatient beds.

multivariate model and are shown in Table 2. HosmerLemeshow goodness-of-fit test showed P .955, which indicates model fit. Daily occupancy 95% remained significant (adjusted odds ratio [OR] 1.73; 95% CI, 1.26-2.39), as
did triage category (adjusted OR 0.20; 95% CI, 0.17-0.24)
and particular diagnoses (injury and poisoning [adjusted OR
1.62; 95% CI, 1.22-2.84], respiratory [adjusted OR 2.48;
95% CI, 1.37-4.49], and circulatory [adjusted OR 3.24; 95%
CI, 1.80-5.80]).

DISCUSSION
The current study demonstrated a positive correlation between high daily hospital occupancy and serious complication rates within the initial 24 hours postadmission request,
of those patients boarded in the emergency department and
managed by emergency department providers. Multivariate

analysis demonstrated that daily occupancy 95%, triage

category, and specific diagnoses (injury and poisoning, respiratory, and circulatory) were independently associated
with high risk for serious complications.
Although there were a number of studies examining the
effects of hospital crowding, relatively few have examined
emergency department boarding and the quality of care for
those boarded patients. In a 162-patient pilot study examining undesirable events among emergency department
boarders, 27.8% of patients had undesirable events while
boarded in the emergency department, especially older patients or those with more comorbidities.12 Moreover, the
incidence is proportional to the emergency department
boarding hours: 42.1% for boarding 6 hours, and 29.0%
and 15.6% for 4-6 hours and 0-2 hours, respectively. However, most of the adverse events in this study were minor

416.e6

The American Journal of Medicine, Vol 125, No 4, April 2012

Table 2

Unadjusted and Adjusted Odds Ratios of Serious Complications

Covariates

Odds Ratio (95% CI)

Male sex
Age
Arrival hour to the ED
8:00 AM-5:00 PM
5:00 PM-8:00 AM
Primary diagnostic category
Digestive
Injury and poisoning
Neurologic
Respiratory
Miscellaneous
Circulatory
Neoplasm
Genitourinary
Infectious and parasitic
diseases
Triage category
Daily ED visits
Daily hospital bed occupancy
Occupancy 90%
Occupancy 90%-95%
Occupancy95%

1.46 (0.99-2.15)
1.01 (1.00-1.02)

Adjusted Odds Ratio (95% CI)

1.00
0.96 (0.78-1.18)
1.00
1.69
1.21
3.10
1.18
2.65
0.88
0.87
1.38

(1.24-2.31)
(0.82-1.80)
(2.29-4.20)
(0.76-1.83)
(1.89-3.72)
(0.52-1.47)
(0.49-1.56)
(0.67-2.86)

1.00
1.62
0.76
2.48
1.54
3.24
0.97
0.71
1.59

(1.22-2.84)
(0.31-1.84)
(1.37-4.49)
(0.76-3.12)
(1.80-5.80)
(0.40-2.35)
(0.22-2.36)
(0.48-5.31)

0.28 (0.25-0.32)
1.00 (1.00-1.00)

0.20 (0.17-0.24)

1.00
1.21 (0.83-1.78)
1.70 (1.23-2.33)

1.00
1.23 (0.84-1.80)
1.73 (1.26-2.39)

CI confidence interval; ED emergency department.

ones such as missed home medication or missed laboratory

checks. To our knowledge, no previous study has explored
the effect of hospital occupancy on serious complications of
emergency department boarders like those in our study.
Currently, hospitals are under tremendous pressure to
maximize revenue while minimizing cost. The priority in
many hospitals is to schedule elective admissions while
using the emergency department to be the buffer for hospital
overflow. This often necessitates boarding in the emergency
department.13 At times of high hospital occupancy and
subsequent emergency department crowding, both physical
and staff capacity are reached or exceeded, and it is plausible that patients presenting at these times receive a lower
quality of care because the available resources are stretched
too thinly.7 Moreover, for some special patients, emergency
department staff may be less familiar with standard service
guidelines for care of the patients condition or the clinical
cues associated with potential serious complications.14 Hospital occupancy above 90% has been demonstrated to be
closely associated with emergency department access block
and is associated with an increased ED LOS.15 Surprisingly,
an additional 100-minute delay was recorded in transferring
patients from the emergency department if the morning
Medical/Surgical bed occupancy was higher than 92%.16 In
addition, another Australian study found that hospital and
emergency department crowding were associated with an
increased 2-, 7-, and 30-day mortality with statistically
significant hazard ratios of 1.3, 1.3, and 1.2, respectively.14
In our study, occupancy 95% was an independent risk
factor for serious complications in emergency department

boarders. An increase in serious complications with boarding admitted patients in the emergency department is a
plausible mediator of the relationship between crowding
and increased mortality.
According to an Institute of Medicine report, high-quality care for emergency department patients should be assessed in 6 domains: safety, timeliness, patient-centeredness, efficiency, effectiveness, and equity.17 Given these
criteria, what might our findings mean for emergency department boarders safety? Because most hospitals currently
operate at very high occupancy, our findings must be taken
into consideration to ensure that our emergency patients
have access to the care they need and deserve. However,
reducing boarding time in the emergency department for
admitted patients requires that inpatient nursing, housekeeping, and administrative structures be properly resourced to
accommodate these admissions, even in the evening hours
when most emergency departments are at peak volume.6
As practiced at SRRSH, allowing flexibility among service locations would reduce emergency department boarding associated with a lack of capacity in a particular unit.
Consequently, the emergency department peaks were
spread over more physicians and nurses. This may partially
explain the observation that the incidence of serious complications in our study was significantly correlated with
occupancy 95% rather than the commonly reported
threshold of 90%.15 A flexible assignment of service location could mitigate, to some extent, the effect of hospital
occupancy on serious complications of emergency department boarders. More important, in the event of emergency

Zhou et al

High Hospital Occupancy Poses Risk for ED Boarders

department crowding, admitted patients should be promptly

distributed to inpatient care providers, even if these patients
are physically located in an emergency department.18,19
Hence, instead of looking at the emergency department as
an independent entity, each unit of the hospital should see
itself as one step of many for the patient in the continuum of
care. A patient-centered model, not location, needs to be the
emphasis of the delivery of care.13 Therefore, therapeutic
interventions that are traditionally initiated during the ward
phase of an admission could be implemented while the
patient remains in the emergency department awaiting a
bed.
Our study has several limitations. First, our study
demonstrated the findings by retrospective chart review
in a single institution and a particular country, which
may raise concerns about the generalization of the study.
However, previous studies have demonstrated an association between prolonged ED LOS and increases in
morbidity and mortality in unclassified patients, intensive care patients, and patients with non-ST-segment
elevation myocardial infarction in Australia and the
US.7,14,20,21 Common among these patients is the need
for both time-sensitive intervention and continuous monitoring, as with those patients in our study with the
specific diagnoses shown to be associated with increased
serious complications. Therefore, the underlying reason
for the above correlation might be due to the fact that
patients with prolonged ED LOS, such as emergency
department boarders, tend to be less closely monitored or
treated less aggressively as staff attention is diverted to
the triage and treatment of new patients. Hence, we
believe our findings can be generalized to other hospital
structures. Secondly, we only evaluated the incidence of
new-onset shock, need for intubation, and death. We did
not examine other serious complications such as dysrhythmia, cardiac arrest, and unplanned admission to the
ICU. Lastly, we did not evaluate the staffing of emergency department and targeted wards in the study. Staffing levels are thought to be one underlying mediator of
impact of the crowding and high occupancy on serious
complications, as assessed in our study.
In summary, the current study showed that daily occupancy 95%, triage category, and specific diagnoses (injury
and poisoning, respiratory and circulatory) were independent risk factors for serious complications for emergency
department boarders managed by emergency department
providers.

ACKNOWLEDGEMENTS
The authors are indebted to Yun-Xian Yu, MD, PhD, for
statistical assistance, and John Reeves, MD, FRACP,
FCICM and Keith Rouleau, MSM, PA-C, for article editing.

416.e7

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