ORIGINAL RESEARCH CONTRIBUTION

Emergency Department Overcrowding

and Inpatient Boarding: A Statewide Glimpse
in Time
Brent M. Felton, DO, Earl J. Reisdorff, MD, Christopher N. Krone, MD, and Gus A. Laskaris, MD

Abstract
Objectives: This was a point-prevalence study designed to quantify the magnitude of emergency depart-
ment (ED) overcrowding and inpatient boarding. Every ED in Michigan was surveyed at a single point
in time on a Monday evening. Given the high patient volumes on Monday evenings, the effect on
inpatient boarding the next morning was also reviewed.
Methods: All 134 EDs within the state of Michigan were contacted and surveyed on Monday evening,
March 16, 2009, over a single hour and again the following morning. Questions included data on annual
census, bed number, number of admitted patients within the ED, ambulance diversion, and ED length of
stay.
Results: Data were obtained from 109 of the 134 (81%) hospitals on Monday evening and 99 (74%) on
Tuesday morning. There was no difference in annual visits or ED size between participating and nonpar-
ticipating EDs. Forty-seven percent of EDs were boarding inpatients on Monday evening, compared
with 30% on Tuesday morning. The mean estimated boarding times were 3.7 hours (Monday evening)
and 7.2 hours (Tuesday morning). Twenty-four percent of respondents met the definition of over-
crowded during sampling times. There was a significant relationship between inpatient boarding and
ED overcrowding (p < 0.001). Only three EDs were actively diverting ambulances.
Conclusions: In this study on a single Monday evening, 47% of EDs in Michigan were actively boarding
inpatients, while 24% were operating beyond capacity. On the following morning (Tuesday), EDs had
fewer boarded inpatients than on Monday evening. However, these boarded inpatients remained in the
ED for a significantly longer duration.
ACADEMIC EMERGENCY MEDICINE 2011; 18:1386–1391 ª 2011 by the Society for Academic
Emergency Medicine

E
mergency department (ED) overcrowding is a
worsening phenomenon across the United
States. As many as 96% of ED directors report
overcrowding as a problem, with 28% claiming that this
is a daily occurrence.1 As the safety net for critically ill
patients, the ED serves a vital role in health care deliv-
ery and public safety. Overcrowding threatens the abil-
From the Department of Emergency Medicine (BMF, EJR),
Michigan State University, East Lansing, MI; Emergency Medi-
cine, Bristol Regional Medical Center (CNK), Bristol, TN; and
Emergency Medicine, Willis-Knighton Medical Center (GAL),
Shreveport, LA.
Received March 16, 2011; revision received May 18, 2011;
accepted June 6, 2011.
The authors have no relevant financial information or potential
conflicts of interest to disclose.
Supervising Editor: Michael Mello, MD.
Address for correspondence and reprints: Brent Felton, DO;
e-mail: feltonbr@gmail.com.
ity to provide timely care to these severely ill patients.
In addition to an increase in ED resource use, boarding
admitted patients who are awaiting placement into
inpatient beds is a significant factor contributing to
overcrowding.2 The secondary effects of overcrowding
include an increase in patient wait times, an increase in
patients leaving without being seen, a decline in overall
patient satisfaction survey scores, and an increase in
ambulance diversion.3,4 For critically ill patients, inpati-
ent boarding often delays transfers to the intensive
care unit and can result in higher mortality rates and
increased lengths of stay.5
In 2008, EDs in Michigan had 4.4 million patient
visits.6 At 44.4 ED visits per 100 population, Michigan’s
ED use was slightly greater than the national average.
In 2007, there were 39.9 ED visits per 100 population in
the United States and 39.7 ED visits per 100 population
in Ontario, Canada.7 Nationally, the number of ED visits
increased from 90 million in 1992 to 108 million visits
by year 2000,8 finally reaching 124 million in 2008.9

ISSN 1069-6563 ª 2011 by the Society for Academic Emergency Medicine

1386 PII ISSN 1069-6563583 doi: 10.1111/j.1553-2712.2011.01209.x
ACADEMIC EMERGENCY MEDICINE • December 2011, Vol. 18, No. 12
Over this same 8-year period, the number of
hospital-based EDs in the United States dropped from
6,000 to fewer than 4,000.8 For many of the remaining
EDs, the increased patient volumes coupled with a
reduction in inpatient hospital bed availability has
resulted in ED inpatient boarding and conditions of
overcrowding.
The primary goal of this study was to determine the
magnitude of statewide ED overcrowding and inpatient
boarding at a single point in time. Due to the high patient
volumes of ED patients on Monday evenings, Monday
evening was selected for the sampling period for our
study. Furthermore, a previous point-prevalence study
by Schneider et al.10 evaluating ED overcrowding and
inpatient boarding was similarly conducted on a typical
Monday evening in March. Given the anticipated over-
crowding and boarding conditions that can occur on
Monday evening, the subsequent conditions on the
following morning (Tuesday) were measured by repeat
surveying of each ED in the state.
METHODS
Study Design and Population
This was a point-prevalence survey. EDs were indenti-
fied using the 2007 to 2008 Michigan College of Emer-
gency Physicians (MCEP) ED directory.11 This reference
lists all EDs in Michigan along with contact informa-
tion. It represents the most accurate data assembled
about Michigan EDs. Given the nature of the reported
data, the institutional review board waived the require-
ments for the participation of human subjects.
Survey Content and Administration
About 2 weeks prior to the survey dates, one investiga-
tor contacted every Michigan ED to inform them of this
process and to obtain consent for the survey.
Demographic data (e.g., bed number, annual visits)
were confirmed at this time. This method provided the
most up-to-date information about every ED in
Michigan. Following confirmation of ED bed number
for each department, beds were then divided into three
categories: ED regular beds (excluding urgent care and
observational beds), nonregular beds (e.g., ‘‘hall beds’’
or non–regularly staffed patient treatment beds), and
observation beds. Observation beds only included those
that were designated as such and were regularly
staffed. A copy of the data survey was electronically
sent to all hospital EDs. Prior to executing the survey,
the nine-member team was briefed on survey
techniques and the requisite data (Figure 1). One
emergency medicine (EM) faculty, five EM residents
(including the investigators), and three undergraduate
research assistants composed the survey team.
A telephone survey of all Michigan EDs was con-
ducted on Monday, March 16, 2009, between 6:00 PM
and 7:00 PM, and again on Tuesday, March 17, between
7:00 AM and 8:00 AM. Calls were made at these times to
best avoid shift changes as determined in prior com-
munications with ED medical and nursing leadership.
During the time of the survey, any ED that chose not
to participate was recontacted within the 60-minute
survey period for a second opportunity to provide
• www.aemj.org 1387
How many patients are currently being seen in the ED
(total)? _____
How many patients are currently being seen in the ED in
regular beds (regular beds are those that are numbered and
do not count hall beds, rooms that have been doubled, or
other space not normally used for patients)? _____
How many patients are currently being seen in the ED in
hall beds or other nonregular beds? _____
How many ED patients have admitting orders and are
waiting for inpatient bed placement? _____
What is the current reason that patients are being boarded
after admission orders have been written?
______________________________________
What is the estimated average length of stay for the patients
you are currently boarding? _____ hrs.
For the patient having been boarded the longest, how much
time (approx.) have they been in the ED? _____ hrs.
Are you currently on ambulance diversion? Circle Y / N
To the best of your knowledge, have you been on
ambulance diversion in the past 24 hours? Y / N
Figure 1. Survey questionnaire.
data. Data included the number of patients currently
being seen in the ED, where patients were being seen
(regular beds versus nonregular or hall beds), the
number of boarded patients, the reason for ED board-
ing, and the presence or absence of ambulance diver-
sion. Best estimates for mean and longest ED inpatient
boarding times were recorded during this 1-hour
window.
Measures
The term ‘‘overcrowded’’ was defined as the presence
of any ED patient being seen in a ‘‘nonregular bed’’ or
non–regularly staffed patient care area such as an ED
cart in the hallway or having a patient-to-treatment
area ratio of >1.0. ‘‘Boarding’’ was defined as having an
admitted patient in the ED who was unable to leave the
ED due to any reason such as a lack of inpatient beds
or a shortage of nursing staff.
Data Analysis
Data were recorded manually on data collection sheets
by each of the surveyors and subsequently transferred
into a data spreadsheet (Excel, 2003, Microsoft Corp.,
Redmond, WA) for further analysis. Descriptive analy-
sis was used as well as chi-square for nominal data and
Student’s t-test interval data comparisons. Fisher’s
exact test was used for nominal data where an expected
result was < 10. For all data when means were
expressed, 95% confidence intervals (CIs) were also
1388
determined. Significance for all results was defined as
a < 0.05.
RESULTS
All 134 Michigan EDs listed in the MCEP directory
were successfully contacted Monday evening within the
60-minute survey period. Of these, 109 (81.3%) chose to
participate in the survey. Of the 25 EDs that did not
participate, 15 cited that they were ‘‘too busy’’ (60%),
eight did not feel ‘‘comfortable’’ answering the survey
questions (32%), one ED hung up on the surveyor (4%),
and one call was routed to an answering machine (4%).
There were no statistical differences in volume or ED
size (bed number) between hospitals that participated
in the study and those that did not (Table 1). The mean
numbers of ED beds were similar (p = 0.65) for partici-
pating hospitals (22.0 beds; 95% CI = 18.3 to 25.7 beds)
and nonparticipating hospitals (23.9 beds; 95%
CI = 16.6 to 31.3 beds). Likewise the mean annual ED
censuses were similar (p = 0.60) for participating
(29,580 visits; 95% CI = 24,835 to 34,325 visits) and non-
participating hospitals (33,000 visits; 95% CI = 21,190 to
44,810 visits).
Of the 109 participating EDs, 26 (23.9%) reported
overcrowding during the survey period, and 51 (46.8%)
were actively boarding inpatients. For EDs boarding
patients, 32 (62.7%) were due to a lack of inpatient bed
availability, 16 (15.8%) were due to a delay in the admit-
ting process, and the remaining 21.5% were for other
and unknown reasons. The mean reported boarding
time per patient was 3.7 hours (95% CI = 2.5 to
4.9 hours). The times for the longest boarded patient
ranged from 15 minutes to 33 hours, with a mean maxi-
mum boarding time of 8.3 hours (95% CI = 5.6 to
11.0 hours). Of the 26 departments reporting over-
crowding, 12.4% of all patients treated in these depart-
ments were being treated in hall beds with a mean
(±SD) of 6.4 (±6.14) hall bed patients per ED. Of the 51
EDs boarding inpatients, the mean number of boarded
patients per ED was 5.5 (SD ± 6.25), with a median of
3.0 patients per ED (range = 1–30; third quartile = 8.0
and first quartile = 1.00). When EDs were subdivided
into interquartile ranges according to bed number, the
quartile of EDs with the largest bed numbers (32 to 89
beds) represented 65% of all overcrowded EDs in the
state (Table 2). Furthermore, 43% of all EDs in the state
boarding inpatients were represented by this same
quartile. There was a statistically significant relationship
between ED overcrowding and ED inpatient boarding
Table 1
Mean Census and Bed Number for Participating and Nonparticipating EDs
Participating EDs
Monday
Annual census 29,580 (24,835–34,325)
Mean bed number 22.0 (18.3–25.7)
Tuesday
Annual census 29,916 (25,083–34,749)
Mean number 21.0 (17.7–24.3)
Data are reported as mean (95% CI).
Felton et al. • ED OVERCROWDING AND INPATIENT BOARDING
(p < 0.001). Only three hospitals were on ambulance
diversion during the study period. There was no
demonstrable relationship between inpatient boarding
and ambulance diversion (p = 0.10). There was,
however, a significant relationship between ED over-
crowding and ambulance diversion (p = 0.02).
On Tuesday morning, all 134 Michigan EDs were
again contacted within the 60-minute survey period; 99
(73.9%) chose to participate. This was a similar
response to Monday’s participation (p = 0.14). Of the 35
EDs that did not participate, 15 cited that they were
‘‘too busy’’ (43%), 11 simply refused to participate
(31%), and nine did not participate for other and
unknown reasons (26%). In comparing participating
and nonparticipating hospitals, both had similar mean
ED sizes (bed numbers) of 21.0 (95% CI = 17.7 to 24.3)
and 26.3 (95% CI = 18.3 to 34.3) beds, respectively
(p = 0.23; Table 1). Likewise, the mean annual censuses
were the same (p = 0.84) for participating hospitals
(29,916 visits; 95% CI = 25,083 to 34,749 visits) and non-
participating hospitals (31,073 visits; 95% CI = 21,088 to
41,058 visits).
Among the 99 participating hospitals, 30 EDs reported
boarding inpatients (30.3%). There was a statistically sig-
nificant reduction in ED boarding between Monday eve-
ning and Tuesday morning (p = 0.04). The mean boarded
time for patients on Tuesday morning was 7.2 hours
(95% CI = 5.1 to 9.3 hours), which was significantly
longer than for Monday evening (p = 0.004). The times
for the longest boarded patient ranged from 30 minutes
to 48 hours, with a mean boarding time of 13.1 hours
(95% CI = 8.9 to 17.3 hours).
DISCUSSION
Several studies have attempted to quantify the extent of
ED overcrowding and inpatient boarding. Schneider et
al.10 used a point-prevalence model in a mailed survey
to assess overcrowding in 250 randomly selected EDs.
Similar to our study, a Monday in March was chosen
for sampling as Monday is the busiest day of the week
for most departments. Schneider’s survey obtained a
response rate of 36%.10 Of these respondents, 73% of
EDs reported inpatient boarding of two or more
patients and an ambulance diversion rate of 11%. Of all
ED patients during this ‘‘snapshot’’ in time, 22% were
admitted and waiting transfer to an inpatient bed.10
In another mail-based survey that involved ED direc-
tors in Florida, New York, and Texas, significant condi-
tions of overcrowding were reported.12 The goal of that
Nonparticipating EDs p-value
33,000 (21,190–44,810) 0.60
23.9 (16.6–31.3) 0.65
31,073 (21,088–41,058) 0.84
26.3 (18.3–34.3) 0.23
ACADEMIC EMERGENCY MEDICINE • December 2011, Vol. 18, No. 12
Table 2
Analysis of Overcrowding and Inpatient Boarding by Quartiles
for ED Size
Number Number of Hospitals Number of Hospitals
of Beds Overcrowded Boarding Inpatients
0–8 3 5
9–13 3 7
14–31 3 17
32–89 17 22
study was to not only determine the incidence of
overcrowding in EDs, but also the factors that most
contributed to these conditions. Importantly, this study
did not have a restricted time interval to consider when
reporting. The survey response rate was 70%, which
was considerably higher than the 36% response rate in
Schneider’s survey. Among respondents, a mean of
97% of urban EDs across these three states reported
overcrowding as a problem. In rural EDs, 83% of direc-
tors still reported conditions of overcrowding. Hospital
bed shortages and increasing patient volumes were the
most commonly cited reasons for these conditions.
Conditions of ED overcrowding and inpatient board-
ing are not isolated to the United States. A mail-based
survey was sent to 243 EDs throughout Canada.13 ED
directors were asked to complete a 54-question survey
assessing the incidence of ED overcrowding as well as
the contributing factors. Among the respondents, 62%
reported overcrowding was a ‘‘major’’ or ‘‘severe’’ pro-
blem in the previous year, with 85% reporting a lack of
admitting beds as the primary contributing factor.
A retrospective study from Perth, Australia, reviewed
the relationship between inpatient boarding and
ambulance diversion, overcrowding and ED wait
times.14 The study identified ‘‘access block’’ (inpatient
boarding > 8 hours) as the primary cause of ED over-
crowding. Periods of high ED occupancy caused from
access block resulted in a 74% increase in ambulance
diversion time. Conversely, the study demonstrated that
low-acuity patients, total ED patients, and the number
of admissions and discharges did not significantly influ-
ence ambulance diversion time.
In an effort to overcome some of the weaknesses of
prior studies, we conducted a statewide, point-in-time
survey to determine the prevalence of inpatient board-
ing, overcrowding, and ambulance diversion in an
entire state. Point-in-time or cross-sectional studies
have advantages over case–control studies in that they
are based on a general population, as opposed to indi-
vidual or selected cases from within a population. As a
result, these studies tend to be more readily generalized
to broader populations. Furthermore, when compared
with the longevity of cohort studies, cross-sectional stu-
dies offer a glimpse of a population in a more strictly
defined time interval.
Several crowding scales have been developed and
validated in previous studies, but were not used in this
study for several reasons. The National ED Overcrowd-
ing Study (NEDOCS) was a survey validated at eight
academic EDs.15 The generalizability of NEDOCS to
nonacademic EDs has yet to be demonstrated. Further-
• www.aemj.org 1389
more, the mean ED bed number in the NEDOCS study
was 48 beds. Only 13 of 109 respondents in the state of
Michigan had EDs this size or larger. Similarly, the
Emergency Department Work Index was developed at
a single urban academic center.16 This crowding scale
has not been validated in the use of multiple EDs and
therefore was not used in this study. The other main
reason these scales were not used was more logistical.
The survey team was responsible for gathering data for
134 EDs within a 1-hour time window. For this reason,
data involving triage category and wait times were not
prospectively collected.
Unlike previous studies that focused on ED director
survey responses by mail, a significant advantage of
this study was that it was conducted in real time. The
results are therefore less likely to contain a self-reporting
bias when compared to previous studies that relied on
responses sent by mail. This key difference in study
design might account for the lower prevalence of ED
overcrowding and inpatient boarding found in this
study compared to previous studies. Most previous stu-
dies have been based on an admixture of objective and
subjective responses provided by ED directors. There-
fore, the results of these studies are limited in the abil-
ity to perform comparisons among the various studies.
The study published by Schneider et al.10 was a simi-
larly designed point-prevalence study; however,
responses were collected by mail. Because of this mail
collection of responses, the possibility of a self-reporting
bias could not be attenuated. Schneider et al.10 reported
a 51% prevalence of ED overcrowding as defined by
more than one patient per treatment space, compared
with 24% identified in our study. Furthermore, real-
time surveying yielded a response rate of 81% in our
study, compared with 36% reported by Schneider et
al.10 The increased rate of ED participation coupled
with real-time survey responses in our study may have
captured many smaller departments where overcrowd-
ing might not be a concern. Many of these smaller EDs
are less subject to conditions of overcrowding. As a
result, these EDs may not have chosen to participate,
resulting in an increased prevalence of overcrowding
through nonresponse in Schneider’s study.
The results in the study presented here may vary
from other surveys due to demographic differences.
EDs collectively in Michigan may simply not be as over-
crowded as departments sampled in other regions of
the country. In reviewing the various regions sampled
by Schneider et al., the Midwest was found to have a
lower rate of overcrowding at 42% compared with 53
and 50% for regions in the West and South, respec-
tively.10 There was, however, a similar trend between
the Schneider survey and this study demonstrating that
larger departments reported increased rates of
overcrowding compared with smaller departments.
Most previously published studies concerning ED
overcrowding and inpatient boarding have been based
on small samples of EDs, sometimes in an attempt to
illustrate regional or national conditions. This study
included every ED in a single state to obtain a more
comprehensive picture of overcrowding and inpatient
boarding within a defined population. When the demo-
graphics of participating hospitals and nonparticipating
1390
hospitals were compared, they did not differ signifi-
cantly in annual census or bed number. As a result, the
data obtained from the participating EDs in this study
are likely to represent the conditions that most, if not
all, Michigan EDs are facing. There were 24% of Michi-
gan EDs that met the definition of overcrowding during
this 1-hour window. This means that nearly one in four
EDs were operating beyond capacity. Furthermore,
47% of EDs during this period were actively boarding
inpatients, with a mean boarding time of 3.7 hours.
Unlike previous studies examining ED overcrowding
and inpatient boarding that examined a single snapshot
in time, additional data were collected on the following
morning. This second survey provided a more complete
picture of the relationship between ED overcrowding
and inpatient boarding over time. The data showed a
greater percentage of EDs boarding inpatients on Mon-
day evening than on Tuesday morning. This suggests
there is a mild relief in the ‘‘bottlenecking’’ of inpatient
boarding overnight. Furthermore, the ED boarding
time was significantly longer on Tuesday morning when
compared with Monday evening. This suggests there
are fewer ED-boarded inpatients overall on Tuesday
morning, but these patients remain in the ED awaiting
transfer to inpatient beds for significantly longer peri-
ods of time. These findings likely reflect the saturation
of available inpatient beds that occurred on Monday
evening, and that patients boarded on Tuesday morning
were waiting for inpatient beds to become available.
The responses from the current study demonstrated
that ED boarding did not have a significant effect on
ambulance diversion. This conclusion is based on the
low number of EDs on diversion during the limited
time window. The results of this point-in-time study
might underestimate the magnitude of ambulance
diversion. Schull et al.17 reported that increased ambu-
lance diversion times were associated with inpatient
boarding, whereas walk-in patient volume and indivi-
dual ED physician coverage had no significant effect on
diversion time. For patients with high-risk chief com-
plaints such as chest pain, there was a 28% increase in
transport time during periods of ambulance diversion.18
As a solution to the problems of overcrowding and
boarding, several initiatives have been proposed. Using a
computer simulation model, investigators examined ED
length-of-stay after increasing the number of ED beds
versus a reduction in inpatient boarding times.19 This
model showed that increasing the number of ED beds
actually increased ED length of stay from 240 to 247 min-
utes, whereas a reduction in inpatient boarding times
reduced ED length of stay from 240 to 218 minutes. Simi-
larly, Viccellio et al.20 retrospectively examined the safety
of admitted ED inpatients transferred to inpatient hall-
way beds during periods of ED overcrowding. Patients
admitted to hallway beds had lower rates of mortality
then patients admitted to standard inpatient beds with-
out compromising patient safety. Furthermore, when
patients were given the option of boarding in an ED hall-
way or an inpatient hallway until an inpatient room was
available, 59% opted to be transported to an inpatient
hallway bed.21 A retrospective study at a community
hospital in Pennsylvania reviewed 62,588 patient visits
between July 2004 and June 2005.22 By reducing
Felton et al. • ED OVERCROWDING AND INPATIENT BOARDING
inpatient boarding to 120 minutes for all admitted
patients during this period, an additional 3,175 patient
visits could have been accommodated without changes
in staffing or patient care areas. The resultant revenue
loss of these encounters totaled $3.9 million.
The consequences of ED overcrowding are severe.
One study examining mortality as an end point demon-
strated a relative risk of 1.34 for inpatient death when
patients presented to EDs during periods of over-
crowding.23 Furthermore, overcrowding results in
poorer performance in pneumonia quality care mea-
sures, as well as longer inpatient lengths of stay.24,25
Despite these outcome measures, patients are not the
only ones affected by inpatient boarding and ED over-
crowding. The lack of inpatient bed availability for
these busy EDs is a major contributing factor to ED
physician dissatisfaction.26
LIMITATIONS
There are certain limitations to this study. A single
Monday evening in March was selected, similar to
Schneider et al.10 The date was selected to avoid
specific holidays and occurred in the absence of any
specific illness epidemics. As best as the authors could
anticipate, this would have been a typical Monday
evening in the ED. Some census variability would exist
among Monday evenings. Still, this date was selected to
minimize any anticipated unusual circumstances.
Furthermore, the study design being a point-in-time
survey has limitations. A primary limitation is the
restricted ability to assess outcome variability over
time. Without repeated sampling of a population, the
prevalence of the given outcome is limited to the study
window. Furthermore, the absence of repeated data
collection further confines the ability to establish cause-
and-effect relationships for a given outcome. In this
descriptive study, the goal was not to establish a cause-
and effect relationship between ED overcrowding and
inpatient boarding. Despite this, a relationship was
identified between these two variables. Our response
rate, while greater than those of previous studies based
on responses by mail, was 81% and therefore did not
include every possible ED. The majority of the nonparti-
cipating facilities responded that they were ‘‘too busy’’
to participate. It is likely that many of these EDs met
our definition for overcrowding and were operating
beyond capacity. Without data from EDs self-reported
as busy, it is possible that the data obtained from
participating departments underestimated the rates of
overcrowding and inpatient boarding in Michigan.
Furthermore, this study was based on a single snapshot
in time. To increase the reliability of the results,
repeated sampling on multiple Mondays would need to
be performed. There were only three EDs on diversion
during the sampling time. This seems to underestimate
the authors’ experiences and the anecdotal experiences
of others. Gathering data on repeated Mondays and
capturing nonparticipating EDs might garner a more
accurate assessment of ambulance diversion. Finally,
caution should be used in generalizing Michigan results
to other states.
ACADEMIC EMERGENCY MEDICINE • December 2011, Vol. 18, No. 12
CONCLUSIONS
To the best of our knowledge, this is the first study to
highlight the prevalence of ED inpatient boarding and
overcrowding on a comprehensive statewide basis.
Unlike previous studies examining these conditions, this
study was conducted in real time. Forty-seven percent
of all EDs in this point-prevalence survey were actively
boarding inpatients on a typical Monday evening, while
24% were operating under conditions of overcrowding.
Moreover, inpatients boarded in the ED the next morn-
ing waited nearly 50% longer than patients boarded on
Monday evening to be transferred to an inpatient floor
bed. The results of this study demonstrated a significant
relationship between inpatient boarding and ED over-
crowding. This study did not, however, demonstrate a
significant relationship between inpatient boarding and
ambulance diversion, likely due to the low number of
EDs on diversion during our survey window. Given the
results on a typical Monday across Michigan, a nation-
wide survey conducted in real time is needed to
validate the findings of this point-prevalence study.
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