HEALTH POLICY AND CLINICAL PRACTICE/ORIGINAL RESEARCH

Crowding Delays Treatment and Lengthens Emergency

Department Length of Stay, Even Among High-Acuity Patients
Melissa L. McCarthy, ScD
Scott L. Zeger, PhD
Ru Ding, MS
Scott R. Levin, PhD
Jeffrey S. Desmond, MD
Jennifer Lee, MD
Dominik Aronsky, MD, PhD
From the Department of Emergency Medicine, Johns Hopkins University School of Medicine,
Baltimore, MD (McCarthy, Ding, Levin); the Department of Biostatistics, Johns Hopkins University
Bloomberg School of Public Health, Baltimore, MD (Zeger); the Department of Emergency
Medicine, University of Michigan School of Medicine, Ann Arbor, MI (Desmond); the Department of
Emergency Medicine, George Washington University School of Medicine, Washington, DC (Lee);
and the Department of Biomedical Informatics and the Department of Emergency Medicine,
Vanderbilt University Medical Center, Nashville, TN (Aronsky).

Study objective: We determine the effect of crowding on emergency department (ED) waiting room, treatment,
and boarding times across multiple sites and acuity groups.

Methods: This was a retrospective cohort study that included ED visit and inpatient medicine occupancy data for
a 1-year period at 4 EDs. We measured crowding at 30-minute intervals throughout each patient’s ED stay. We
estimated the effect of crowding on waiting room time, treatment time, and boarding time separately, using
discrete-time survival analysis with time-dependent crowding measures (ie, number waiting, number being
treated, number boarding, and inpatient medicine occupancy rate), controlling for patient demographic and
clinical characteristics.

Results: Crowding substantially delayed patients’ waiting room and boarding times but not treatment time.
During the day shift, when the number boarding increased from the 50th to the 90th percentile, the adjusted
median waiting room time (range 26 to 70 minutes) increased by 6% to 78% (range 33 to 82 minutes), and the
adjusted median boarding time (range 250 to 626 minutes) increased by 15% to 47% (range 288 to 921
minutes), depending on the site. Crowding delayed the care of high-acuity level 2 patients at all sites. During
crowded periods (ie, 90%), the adjusted median waiting room times of high-acuity level 2 patients were 3% to
35% higher than during normal periods, depending on the site and crowding measure.

Conclusion: Using discrete-time survival analysis, we were able to dynamically measure crowding throughout
each patient’s ED visit and demonstrate its deleterious effect on the timeliness of emergency care, even for
high-acuity patients. [Ann Emerg Med. 2009;54:492-503.]

Provide feedback on this article at the journal’s Web site, www.annemergmed.com.

0196-0644/$-see front matter
Copyright © 2009 by the American College of Emergency Physicians.
doi:10.1016/j.annemergmed.2009.03.006

SEE EDITORIAL, P. 511.
INTRODUCTION
Background
Length of stay is an important measure of quality of care in
the emergency department (ED).1-3 Several studies have found
that crowding is associated with increased ED length of stay.4,5
Rathlev et al4 observed that daily ED length of stay was
positively associated with the hospital occupancy rate and
number of emergency admissions at their institution. Asaro et
al5 found that at their ED, crowding factors increased wait time
and boarding time but not treatment time. In contrast, Schull et
al6 investigated the effect of the number of low-complexity
patients on the length of stay of higher-complexity patients
treated at EDs in Ontario, Canada, and found that increasing
numbers of low-complexity patients did not significantly
lengthen the wait time or ED length of stay of higher-
complexity patients.
Importance
Many hospital-based EDs across the country have been
struggling with crowding for more than a decade.7,8 Until
recently, there were few objective measures of crowding and
modest evidence of the negative effects of crowding on
patient care and outcomes. However, advances in crowding
measures during the past 5 years have resulted in a growing
number of studies that quantify the negative consequences of
crowding, especially on delays in care for time-sensitive

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McCarthy et al
Editor’s Capsule Summary
What is already known on this topic
Emergency department (ED) crowding often results
from limited hospital functional capacity and can
affect patient care and outcomes.
What question this study addressed
How does ED crowding alter the time to initiate
care, ED treatment time, and ED boarding time
after admission, and are these effects similar across
patient illness acuities?
What this study adds to our knowledge
In this 4-ED retrospective analysis of more than
225,000 visits, increased ED crowding delayed the
start of care and lengthened boarding time without
altering the length of the treatment phase of ED
care. This pattern was observed in both high- and
low-acuity patients.
How this might change clinical practice
These data confirm that ED crowding spares few
and that sicker patients are affected, and it confirms
the need for creative solutions.
conditions.7,9-13 One of the major limitations of crowding
studies conducted to date is that they measure crowding in a
static way, either at a point in time (eg, patient arrival) or by
averaging crowding during a specific interval (eg, a shift).
However, many studies have shown that crowding is
dynamic and can fluctuate substantially during the course of
a patient’s ED stay.14-17
Goals of This Investigation
The purpose of this study was to quantify the relationship
between crowding and ED length of stay at 4 hospital EDs
and to compare the effect across EDs and patient acuity
levels. We measured crowding at regular intervals throughout
each patient’s ED stay and estimated the cumulative effect of
crowding on ED waiting room time, treatment time, and
boarding time, using discrete-time survival analysis, which
allowed us to include time-varying crowding covariates. We
stratified the analysis by shift, site, and patient acuity and
determined whether crowding, adjusted for other factors,
significantly delayed completion of each phase of ED care.
MATERIALS AND METHODS
Study Design
This investigation was based on a retrospective cohort design
that included all ED visits to one of 4 hospital EDs during a
1-year period. Patient visit information was abstracted from the
information system of each ED and combined with inpatient
Volume , .  : October 
Crowding and Length of Stay
medicine occupancy and ED staffing data. The institutional
review board of each site approved the study by expedited
review.
Setting
The selection of the 4 study sites was based on previous
collaboration and feasibility of aggregating electronic medical
record data across the different sites.14,15 The 4 study sites are
geographically dispersed; all but 1 is located in an inner city
with a population of more than 500,000 residents. All of the
study EDs are part of tertiary care, academic medical centers
with Level I trauma centers. Three of the 4 study sites have
separate pediatric EDs whose visit data were excluded. However,
if a pediatric patient was treated in the study ED, the visit was
retained. Table 1 displays the 4 sites by facility, staffing, and
crowding characteristics. The 4 study sites differ in terms of
inpatient medicine bed capacity (range 224 to 461 beds) and
ED capacity (range 26 to 41 beds in main ED). The annual ED
volumes across the study sites range between 50,000 and
62,000. Two of the study EDs have an observation unit and 1
has a dedicated laboratory. At 2 study sites, inpatient physicians
are primarily responsible for boarders, whereas at the other 2
facilities, emergency physicians remain responsible (ED nurses
continue to provide care to boarders at all sites).
The 4 sites also differ substantially by staffing and crowding
factors (Table 1). The difference in the median number of
attending physicians or residents working per hour is 1 across
the sites. However, the difference in the median number of
nurses working per hour is 11 between the ED with the most
versus fewest nurses. The median number boarding during a
30-minute period at one of the study EDs is twice the median
number (median⫽10) of another ED (number⫽5). There is
substantial variation both within and across the 4 study sites in
the hourly ED occupancy rate. The variation in the inpatient
medicine occupancy rate within and across the study sites is
smaller but still considerable.
All 235,928 ED visits that occurred at one of the 4 study
sites during a 1-year period (October 1, 2006, to September
30, 2007, for 3 sites and October 1, 2005, to September 30,
2006, for 1 site) were eligible for the study. We eliminated
4% of ED visits across all 4 sites because of registration
errors (N⫽5,986), because patients were sent elsewhere and
not treated in the ED (ie, mainly labor and delivery)
(N⫽2,537), or because patients had multiple missing
(N⫽226) or prolonged ED times (ie, wait time ⬎12 hours,
treatment and boarding time ⬎48 hours) (N⫽645). We
were left with 226,534 ED visits.
Methods of Measurement
The premise of this study was that when crowding occurred,
demand exceeded capacity and delays were more likely. During
the course of a patient’s ED stay, crowding levels fluctuate,
often substantially. Thus, an analysis of crowding must take into
account the time-varying nature of crowding. To capture
crowding changes during each patient’s length of stay, we used a
Annals of Emergency Medicine 493
Crowding and Length of Stay McCarthy et al

Table 1. Description of study sites.

Site A Site B Site C Site D
Facility
Annual ED volume 57,691 56,832 50,824 61,187
No. of staffed ED beds (IQR) 46 (46, 53) 43 (43, 48) 43 (41, 45) 36 (26, 36)
Main ED beds 32 27 41 26
Fast track beds 7 5 4 10
Observation beds 14 16 0 0
Level I trauma center Yes Yes Yes Yes
No. of inpatient medicine beds 224 287 461 246
Where majority of laboratory services ED Central Central Central
processed
Point-of-care testing available Yes Yes No Yes
ED physicians responsible for ED boarders Yes No No Yes
Left without being seen rate (%) 3 4 3 3
Staffing
Median no. of physicians per hour (IQR) 3 (1, 4) 3 (2, 3) 3 (2, 4) 2 (1, 2)
Median no. of residents per hour (IQR) 4 (4, 5) 3 (2, 3) 4 (4, 5) 4 (4, 4)
Median no. of nurses per hour (IQR) 15 (14, 17) 21 (18, 22) 14 (12, 15) 10 (8, 11)
Median hourly staffing/bed (IQR) 0.45 (0.42, 0.47) 0.54 (0.49, 0.60) 0.51 (0.45, 0.53) 0.50 (0.47, 0.53)
Median hourly staffing/patient (IQR) 0.52 (0.45, 0.62) 0.56 (0.47, 0.68) 0.58 (0.48, 0.74) 0.43 (0.35, 0.54)
Crowding
Median no. waiting/30 min (IQR) 8 (5, 12) 4 (2, 8) 2 (1, 6) 7 (3, 12)
Median no. being treated/30 min (IQR) 28 (24, 33) 33 (27, 38) 22 (17, 28) 23 (17, 28)
Median no. boarding/30 min (IQR) 5 (3, 7) 7 (4, 11) 10 (5, 16) 6 (4, 9)
Median hourly ED occupancy rate (IQR) (%) 86 (70, 102) 97 (77, 120) 75 (57, 93) 116 (89, 143)
Median hourly inpatient medicine 83 (77, 87) 90 (86, 93) 78 (75, 80) 83 (77, 87)
occupancy rate (IQR)
Median ED length of stay, min (IQR)
Discharged 240 (109, 451) 285 (163, 465) 238 (144, 374) 231 (152, 343)
Admitted 463 (318, 663) 449 (319, 642) 397 (218, 748) 481 (358, 630)

“counting process approach.”18 We divided each patient’s
length of stay into a sequence of contiguous time periods and
observed when (ie, which interval) each patient completed a
particular phase of ED care.
We measured 3 phases of ED care: (1) waiting room time,
defined as time from registration to room placement; (2)
treatment time, defined as time from room placement to
disposition decision; and (3) boarding time, defined as time
from disposition decision to ED-hospital transfer for patients
admitted. Completion of waiting room time was measured in
15-minute intervals (eg, noon to 12:14 PM, 12:15 to 12:29 PM),
whereas completion of treatment and boarding time was
measured in 30-minute intervals (eg, noon to 12:29 PM, 12:30
to 12:59 PM).
We measured multiple crowding factors corresponding to
the 3 phases of emergency care. We divided the 1-year study
period into 30-minute intervals and measured crowding
every 30 minutes (starting on the hour and the half-hour)
throughout the study period. Crowding measures capture the
number of patients within each phase of care at any time
during each 30-minute discrete interval. For example, a
patient being treated during an entire 30-minute interval is
counted as 1 treatment patient. A patient who is treated for
10 minutes in the interval and then boards for the remaining
20 minutes is counted as one-third treatment patient and
two-thirds (ie, 20 minutes/30 minutes) boarding patient,
respectively. Thus, the sum of patients during each 30-
minute interval was not limited to integer values, but may be
counted as a fraction.
To characterize hospital crowding, we also measured the
inpatient medicine occupancy rate. Because the majority of ED
patients are admitted to medicine wards, we considered the
inpatient medicine units to have a greater effect on ED length of
stay than the overall hospital census. For 3 of the sites, the
inpatient medicine occupancy rates were available hourly
throughout the study period, so we used the rate closest to the
previous hour (eg, noon) as the crowding value for the intervals
that started on the half hour (eg, 12:30 PM to 12:59 PM). For
one site, the inpatient medicine occupancy rate was measured
every 6 hours, so we interpolated it linearly between each
measurement period.19 To validate the linear interpolation
approach we used at this one site, we linearly interpolated the
hourly measures at the 3 other sites and found a strong
correlation between the interpolated and observed values
(r2⫽0.77, 0.94, and 0.97).
The bottom half of Figure 1 depicts how we characterized
completion of the different phases of ED care for 6 patients
randomly selected from a single day at one of the sites. The
first patient on the far left waited 8 minutes before entering
the treatment phase, so the first circle is blackened to
illustrate completion of waiting room time in the first 15-
minute interval. The first patient completed treatment in

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McCarthy et al Crowding and Length of Stay

Figure 1. The top half of the figure displays the values for 3 of the crowding measures at 30-minute intervals for a single,
random day during the study period. This approach allowed us to capture any changes in these crowding factors every 30
minutes throughout the study period. The bottom half of the figure displays how we measured the completion of each
phase of ED care for 6 randomly selected patients during the same day. Completion of waiting room time was measured
every 15 minutes because it is typically short, whereas completion of treatment and boarding time was measured every
30 minutes.

323 minutes, so treatment is depicted as completed by the
11th triangle, which is blackened. Finally, the first patient
boarded for 200 minutes, and this is depicted by the seventh
square, which is blackened.
The top half of Figure 1 shows that we also measured
crowding variables throughout each patient’s ED stay. Because
completion of waiting room time was measured every 15
minutes and the crowding variables were measured every 30
minutes, we used the crowding values from the 30-minute
interval that contained the 2 waiting room intervals (eg, the
number of patients being treated in the interval from midnight
to 12:29 AM was used to reflect crowding in the midnight to
12:14 AM interval, as well as the 12:15 AM to 12:29 AM interval).
For each phase of ED care, we characterized the distribution
of the probability that a particular phase of care would be
completed in each interval, given that it had not been
completed in previous intervals. To estimate the median time to
completion of care, we calculated the probability of completing
care during each successive interval, using a survivorship
function. Because the survivorship function is a step function,
we linearly interpolated the median time to completion of each
phase of care.20 At each interval, we also estimated the effect of
crowding on the probability of completion of a particular phase
of ED care. In this calculation, the effect of crowding on
completion of care accumulates, producing the cumulative
effect of crowding on each length of stay outcome.
To examine the influence of crowding across intervals with
similar ED and hospital resources, we stratified the analysis by
shift (8 AM to 4 PM, 4 PM to midnight, and midnight to 8 AM).
We obtained the physician, resident, and nurse staffing
schedules from each site and initially included staffing in our
analyses. However, this was not necessary after stratifying by
shift because staffing did not vary significantly within a shift at
each site. We excluded the weekend intervals (ie, from Friday
night midnight until midnight on Sunday) from the main
analysis because resources are different on the weekends and
crowding is less common at the study sites. However, Table E1
(available online at http://www.annemergmed.com) includes
the results of the main analysis according to weekend ED visits.
Data Collection and Processing
This study relied primarily on ED visit and hospital census data.
For each ED visit, the following data elements were extracted from
each site’s ED information system: (1) date and time of registration;
(2) date and time of room placement; (3) date and time of initial
contact with physician or midlevel provider, if available; (4) date
and time of disposition decision; (5) date and time of disposition or
transfer to inpatient ward if admitted; (6) disposition status; (7)
demographic characteristics (age, sex, insurance status); (8) triage
level; (9) mode of arrival; and (10) chief complaint. All of the sites
use their ED information system for operational monitoring and
improvement purposes and have processes in place to ensure data
accuracy.
The ED information system at each site is different (2 have
different commercial products and 2 developed their own
system). Despite the different systems, the majority of data were

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Crowding and Length of Stay
documented and stored in a similar way, which facilitated
analysis across the 4 sites. For example, at each site, arrival time
is documented by either a triage nurse or dedicated registration
clerk immediately after the patient presents to the ED. The time
of transition from waiting to a treatment bed is documented by
bed assignment in each ED information system by a nurse or
technician. If bed assignment was missing, we used time to
initial contact with emergency physician or midlevel provider.
At one site, we used the disposition time (completed for both
discharged and admitted patients by a physician) to determine
the time the physician decided to admit the patient, whereas at
the other 3 sites, we used an admission decision order data field
completed by physicians for admitted patients.
All 4 sites use the Emergency Severity Index to triage
patients. The Emergency Severity Index is a 5-level triage scale
that prioritizes patients according to their severity of illness and
anticipated number of resources needed. The index
differentiates patients in terms of urgency: high-acuity patients
who should be treated first (Emergency Severity Index levels 1
and 2) from those less urgent (Emergency Severity Index levels 3
to 5). Among those less urgent, Emergency Severity Index levels
3, 4, and 5 are distinguished according to predicted resources
needed to make a disposition.21-23
Each site’s ED information system has a standard list of chief
complaints, with the option of free text. To standardize the
chief complaints across the 4 sites, we classified each chief
complaint according to the Reason for Visit Classification
System used by the National Hospital Ambulatory Medical
Care Survey.24
From the above data, we calculated each patient’s waiting
room time, treatment time, and boarding time. Across the 4
sites, 7% of visits were missing a data element needed to
calculate either the waiting room time or boarding time. For
these visits, we imputed waiting room time and boarding time
according to acuity, chief complaint, and other timing
information that was available.
Primary Data Analysis
All analyses were conducted in R, version 2.7 (available at
http://www.R-project.org). The following analyses were
conducted separately at each of the EDs. For readers who are
interested in our analytical methods, please see Figure E1
(available online at http://www.annemergmed.com), which
includes the commands we used and the types of output
generated.
First, we examined the frequency distribution of ED wait
time, treatment time, and boarding time. Because all 3
outcomes were positively skewed, we focused the analysis on the
median rather than the mean time. Second, we conducted a
bivariate analysis and examined the relationship between each
covariate and the median time in each of the 3 phases of ED
care. The following categories of covariates were examined: (1)
crowding measures (number of patients waiting, number of
patients being treated, number of boarders, and inpatient
medicine occupancy rate); (2) patient demographics (age, sex,
496 Annals of Emergency Medicine
McCarthy et al
insurance status); and (3) clinical characteristics (chief
complaint, mode of arrival, and acuity level). For the time-
dependent variables (ie, crowding measures), we examined the
proportion of subjects who completed their care by various
levels of crowding. For the time-invariant variables, we
compared the median time to completion for different
categories for each variable.
Third, for each site and shift we used discrete-time survival
analysis to estimate the effect of crowding separately on the
probability of completing waiting room time, treatment time,
and boarding time, adjusted for demographic factors, clinical
characteristics, and variation in follow-up time.25 For each
phase of ED care, we included only crowding factors that would
affect that phase of care or a future phase of ED care. For
example, in the treatment time model, we included the number
of patients being treated, the number of boarders, and the
inpatient medicine occupancy rate, but we did not include the
number of patients in the waiting room because subjects in the
treatment phase should not be affected by patients who are
“behind them” in the ED process. Similarly, in the boarding
time model, we included the number of boarders and the
inpatient medicine occupancy rate, but we excluded the number
of patients in the waiting room and the number of patients
being treated because those patients are not yet competing with
the boarders for an inpatient bed.
To allow for the probability of completion of a phase of care
changing over time, we included a natural cubic spline of time
with 2 df for the wait time models, 3 df for the treatment time
models, and 4 df for the boarding time models. The number of
degrees of freedom selected were based on the log likelihood
ratio test.26 The discrete-time survival analysis models estimate
the cumulative probability of completing a particular phase of
care, and we used these cumulative probability distributions to
linearly interpolate the median predicted waiting room time,
treatment time, and boarding time for the study sample.
Fourth, to evaluate the effect of each crowding variable on
length of stay, we calculated the median completion times of
care from the fitted models under 2 different scenarios: (1)
when all crowding measures were at the 50th percentile; and (2)
when each crowding measure was at the 90th percentile,
holding the other crowding measures at their median values and
the other covariates constant. We did not estimate the effect of
all crowding factors at the 90th percentile simultaneously
because this rarely occurred during the 1-year study period. To
illustrate the overall effect of crowding, we calculated the
average median waiting room, treatment, and boarding times
across the 4 sites by different percentiles of each crowding
factor, holding the other crowding factors at 50%.
Sensitivity Analyses
To examine the validity of our imputation methods, we
compared the visits with missing data to those with no missing
data at each site by patient, clinical, or temporal factors. Because
there were no large differences between the 2 groups, we reran
our models without the imputed data and compared the results
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McCarthy et al Crowding and Length of Stay

Table 2. Percent distribution of patient and clinical characteristics by site.

Site A Site B Site C Site D
Characteristics Nⴝ57,691 Nⴝ56,832 Nⴝ50,824 Nⴝ61,187
Age,
⬍18 2 4 1 2
18–34 33 33 42 37
35–54 43 34 36 39
ⱖ55 22 29 21 22
Sex
Female 52 55 55 52
Male 48 45 45 48
Mode of arrival
Walk-in 80 80 77 80
Ambulance 20 20 23 20
Insurance status
Medicaid 30 12 27 13
Medicare 7 24 16 5
Self-pay 37 5 17 21
Commercial 26 59 40 61
Disposition
Discharged 77 70 72 81
Admitted 23 30 28 19
Acuity level
1 5 1 3 0
2 20 34 38 13
3 50 51 43 42
4 23 12 15 37
5 2 2 1 8
Chief complaint
Injury 15 14 18 21
Digestive 13 17 15 11
Nervous/eyes/ears 7 8 5 6
Cardiovascular 7 12 9 9
Mental 5 2 4 4
Respiratory 12 9 9 9
Genitourinary 5 5 7 5
Skin 2 2 1 2
Musculoskeletal 18 12 13 14
General symptoms 16 19 19 19
Arrival time
12 midnight–8 AM 17 17 17 17
8 AM–4 PM 47 44 44 48
4 PM–12 midnight 36 39 39 35

to the results we obtained with the models that included the
imputed data. Because there were no substantial differences, the
results shown include the imputed data (see Table E2 [available
online at http://www.annemergmed.com] for main results
without imputed data).
RESULTS
The patient populations of the 4 study sites differ substantially
from one another, particularly in terms of insurance status,
admission rate, and acuity level (Table 2). Site A treats more
patients who are uninsured (37%) compared with the other sites
(range 5% to 21%). Site D admits proportionately fewer patients
(19%) than the other EDs (range 23% to 30%). Site D also treats
fewer highly acute patients (ie, Emergency Severity Index levels 1
and 2) (13%) compared with the other sites (range 25% to 41%).
Despite the differences in demographic characteristics and acuity
level, the unadjusted median ED length of stay for patients across
the 4 sites was similar (Table 1).
Table 3 displays the sites’ unadjusted median waiting room
times, treatment times, and boarding times by patient and
clinical characteristics for those visits that occurred during the
week. At all 4 sites, at least 50% of ED patients admitted wait at
least 3 hours before transfer to an inpatient bed. The clinical
characteristics are associated with larger differences in ED length
of stay outcomes compared with the patient characteristics. For
example, the median waiting room time for patients who walk
in is more than double the waiting room time of patients who
arrive by ambulance. ED length of stay is longest for acuity level
2 and 3 patients.
Adjusting for differences in patient and clinical
characteristics, crowding factors consistently delayed waiting
room time and boarding times at all of the sites; however, the

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Crowding and Length of Stay McCarthy et al

Table 3. Median ED length of stay in minutes by patient characteristics.*

Waiting Room Time Treatment Time Boarding Time
Site A Site B Site C Site D Site A Site B Site C Site D Site A Site B Site C Site D
43,862 40,897 35,767 45,104 41,575 39,372 34,998 45,104 9,908 12,802 9,746 8,748
Overall 47 19 19 45 155 232 189 152 195 180 207 286
Age, y
0–34 44 26 24 54 120 201 169 145 175 167 148 255
35–54 51 20 19 44 167 252 211 156 200 181 233 280
ⱖ55 44 13 11 30 180 243 195 158 197 185 219 299
Sex
Female 51 21 22 49 166 244 196 161 200 183 228 291
Male 43 17 15 40 142 215 180 142 191 178 195 280
Mode of arrival
Walk-in 55 25 29 62 145 222 186 141 205 183 299 285
Ambulance 23 7 3 8 190 269 203 210 171 175 122 298
Insurance status
Medicaid 52 20 25 49 174 243 187 182 203 185 197 322
Medicare 48 16 14 45 181 244 208 191 205 183 266 316
Self-pay 44 24 19 41 135 216 185 157 190 168 171 256
Commercial 45 20 17 47 155 231 183 146 187 177 187 278
Disposition
Discharged 50 25 25 51 145 240 199 160 N/A N/A N/A N/A
Admitted 39 11 9 20 176 215 163 114 195 180 207 286
Acuity level
1 3 5 0 0 62 99 34 44 75 116 36 194
2 26 10 12 11 225 249 234 162 206 184 219 286
3 94 35 28 49 220 259 200 209 205 179 343 289
4 37 41 28 57 50 95 99 120 200 165 301 276
5 36 33 27 47 35 57 64 81 261 65 191 312
Chief complaint
Injury 24 18 5 39 89 170 134 126 103 157 74 253
Digestive 73 31 28 57 242 291 250 229 210 184 369 292
Nervous/eyes/ears 44 16 17 32 185 239 187 145 195 181 240 289
Cardiovascular 55 10 13 22 195 283 243 175 180 173 198 293
Mental 57 12 33 23 286 392 288 229 272 154 206 237
Respiratory 41 13 17 39 150 189 176 142 205 198 268 312
Genitourinary 64 33 37 64 166 248 206 188 171 177 214 225
Skin 42 32 34 64 65 161 101 108 224 168 394 336
Musculoskeletal 50 37 26 58 102 193 143 133 200 174 279 285
General symptoms 51 20 26 49 170 226 190 151 195 183 343 294
Arrival time
12 midnight–8 AM 39 11 9 15 185 224 201 169 200 211 212 277
8 AM–4 PM 44 17 18 42 150 248 193 146 205 195 223 304
4 PM–12 midnight 55 33 31 69 148 214 180 153 179 152 176 266
N/A discharged patients do not board.
*Patients who arrived on the weekends are excluded from this table.

magnitude of the effect varied by site. The results based on the
weekday data presented in Table 4 are similar to results
obtained on the weekend data included in Table E1 (available
online at http://www.annemergmed.com).
The crowding factor associated with the longest waiting
room times was the number of patients in the waiting room
(Table 4). For example, during the day shift, an increase in the
number of waiting room patients from 50% to 90% was
associated with an increase in waiting room times of 44% to
158%, depending on the site. The number of patients being
treated and the number of boarders also significantly increased
patients’ waiting room time.
Crowding affected the waiting room time of the EDs, with
the shortest median waiting room times more than that of the
EDs with longer median waiting room times. For example, at
site B during the day shift, the adjusted median waiting room
time increased from 26 minutes to 54 minutes (109% increase)
when the number of patients in the waiting room was at 90%
(11 patients) compared with 50% (4 patients).
In the boarding time models, the number of boarders and the
inpatient medicine occupancy rate both had independent, negative
effects on boarding time. During the day shift, an increase in the
number of boarders was associated with an increase in boarding
time of 15% to 47%, depending on the site. Crowding had the

498 Annals of Emergency Medicine Volume , .  : October 

McCarthy et al Crowding and Length of Stay

Table 4. Impact of crowding on adjusted median times in minutes using discrete-time survival analysis models stratified by shift
†
and site.*
8 AM To 4 PM 4 PM To Midnight Midnight to 8 AM

Site Site Site Site Site Site Site Site Site Site Site Site
Crowding Factors A B C D A B C D A B C D
Waiting room time
‡
Median 70 26 28 68 91 87 55 113 47 15 12 29
No. waiting, 90% 101 54 73 112 115 157 132 161 67 32 18 63
No. being treated, 90% 78 41 46 76 99 108 89 126 57 23 17 37
No. boarding, 90% 74 33 50 82 98 104 96 137 48 20 18 41
Treatment time
‡
Median 258 284 224 201 184 248 193 200 219 258 210 208
No. being treated, 90% 278 289 219 205 195 261 205 213 240 282 215 234
No. boarding, 90% 241 274 214 196 183 252 198 203 220 258 220 219
Inpatient medicine, 90% 264 296 240 205 186 249 195 201 223 258 214 211
Boarding time
‡
Median 250 334 626 334 192 157 288 378 162 125 347 289
No. boarding, 90% 288 410 921 395 208 208 501 420 170 187 967 338
Inpatient medicine, 90% 277 454 896 354 196 159 319 397 169 136 566 314
*Predictions were calculated for patients who were between 35 and 54 years old, were female, had commercial insurance coverage, walked in, and had acuity level 3,
with a chief complaint of general symptoms.
†
Bolded values are statistically significant (P⬍.05).
‡
All crowding factors estimated at median level.

greatest effect on the boarding times of patients at site C during the
overnight shift (ie, midnight to 8 AM). The median boarding time
increased from 347 minutes to 967 minutes (179% increase) when
the number of boarders increased from the median (12 boarders) to
90% (20 boarders) at that site.
In general, crowding factors also had a negative effect on ED
treatment times across the sites, but the increases were relatively
small. For example, during the day shift, the biggest increase
(8%) in median treatment time (20 minutes) was at site A when
the number of patients being treated was high (ie, 37 patients)
compared with normal (ie, 29 patients).
Figure 2 displays the strong effect of the different crowding
factors on ED length of stay averaged over all 4 sites during the
day shift. As observed with the site-specific data, the delay in
care is most marked for waiting room time and boarding time.
The impact of the number of patients boarding and the
inpatient medicine occupancy rate is similar for the waiting
room time and boarding time.
Crowding affected patients differently, depending on their
acuity level (Table 5). The highest acuity patients, Emergency
Severity Index level 1 patients, were not affected by crowding.
Crowding had a strong negative effect on high-acuity level 2
patients and level 3 patients. For example, the adjusted median
waiting room time for high-acuity level 2 patients increased by
13% to 29%, depending on the site, when the number of
patients in the waiting room increased from 50% to 90%. For
level 3 patients, the same increase in the number of waiting
room patients was associated with a 24% to 68% increase in
adjusted median waiting room time. The increase in the
adjusted median boarding time of high-acuity level 2 patients
(range 12% to 83%) and level 3 patients (range 12% to 72%)
was similar when the number of boarders increased from 50%
to 90% at the different sites (Table 5).
LIMITATIONS
The results of this study must be interpreted in the context
of the following limitations. First, this study did not attempt to
connect the different phases of care and determine how the
completion of care in one phase affects the completion of care in
another.
Second, our models did not include all potential covariates
that affect ED length of stay, such as orders for diagnostic tests,
treatments, or specialty consultations. Although overall
treatment times were not significantly delayed by crowding
factors, future research should address how crowding affects
different diagnostic and treatment services.
Third, the definitions of different ED phases of care and
crowding measures were based on somewhat different
operational data, depending on the site. Although this is not
ideal, the benefits of multicenter participation outweighed the
weaknesses of variation in operational data and the results were
consistent across the sites.
Fourth, the inpatient medicine occupancy rate was collected
every 6 hours at one site rather than hourly at the other sites.
However, we developed site-specific models, we linearly
interpolated the hourly measures at one site, and the results of
inpatient medicine occupancy on ED length of stay were
consistent across the sites. Using the inpatient medicine
occupancy rate rather than the overall hospital occupancy rate
may limit the generalizability of the study. However, as
previously found by Rathlev et al,4 hospital occupancy can also
be used to measure crowding; the magnitude of the effect may

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Crowding and Length of Stay McCarthy et al

Figure 2. The effect of different crowding factors averaged across the 4 sites on the adjusted waiting room time,
treatment time, and boarding time for various levels of crowding. The time patients spend in the waiting room or in the ED
boarding increases sharply as the EDs become increasingly crowded.
Table 5. Impact of crowding on adjusted median times in minutes using discrete-time survival analysis models stratified by
†
patient acuity and site.*
‡
Acuity Level 1 Acuity Level 2 Acuity Level 3 Acuity Levels 4 and 5
Site Site Site Site Site Site Site Site Site Site Site Site Site Site
Crowding Factors Site A B C A B C D A B C D A B C D
Waiting room time
§
Median 11 8 N/A 21 11 11 21 50 16 12 35 26 20 12 28
No. waiting, 90% 12 8 N/A 24 12 13 27 64 27 15 54 30 26 14 43
No. being treated, 90% 11 8 N/A 22 12 15 23 60 26 19 43 27 28 15 32
No. boarding, 90% 10 8 N/A 21 12 15 27 55 21 22 50 26 23 17 33
Treatment time
§
Median 149 198 115 227 253 270 208 241 268 211 221 47 104 105 102
No. being treated, 90% 147 191 123 234 254 271 223 262 288 219 235 50 111 107 108
No. boarding, 90% 134 233 123 218 252 275 204 238 266 210 223 46 101 105 104
Inpatient medicine, 90% 154 183 113 234 261 290 212 245 271 218 222 47 104 104 103
Boarding time
§
Median 156 178 88 218 278 559 349 232 268 714 375 N/A N/A N/A N/A
No. boarding, 90% 183 206 101 244 440 1025 401 259 413 1228 449 N/A N/A N/A N/A
Inpatient medicine, 90% 141 175 86 229 320 734 384 248 328 937 394 N/A N/A N/A N/A
N/A, At site C waiting room type was not estimated because there was little variation in waiting room time (95% of patients immediately sent to room on arrival);
boarding times not estimated for acuity level 4 and 5 patients because of small number of patients admitted.
*Predictions were calculated for patients who were between 35 and 54 years old, were female, had commercial insurance coverage, walked in, and had a chief com-
plaint of general symptoms during dayshift.
†
Bolded values are statistically significant (P⬍.05).
‡
Acuity level 1 estimates for site D were not calculated because of inadequate sample size.
§
All crowding variables were estimated at median level.

500 Annals of Emergency Medicine Volume , .  : October 

McCarthy et al
be smaller or larger than the result we found, depending on the
facility and patient population.
Fifth, we used the same calendar period for the analysis at all
4 sites, but one site’s analysis is based on data provided to the
data coordinating center 1 year earlier than the other 3 sites. We
do not believe the results would have been any different at this
site if the data used were from the same year as the other 3 sites.
Sixth, to better understand how hospital operations affect
ED length of stay, it would have been advantageous to have had
information on non-ED patients who are competing with ED
patients for hospital resources (eg, elective admissions,
diagnostic test requests, specialty consultations).
Seventh, a small number of pediatric patients treated at the
four EDs were left in the analysis, but, given the small
proportion, we do not believe it substantially affected the
results.
Eighth, we did not conduct any site-specific evaluations of
the accuracy of the study data. However, the sites have been
using all of the data we relied on in this study for operational
reporting purposes, so the general accuracy of the study data
should be relatively high.
Finally, the study sites were all EDs that are part of tertiary
care hospitals with Level I trauma centers; they are not a
representative sample of hospital EDs in the United States.
Regardless, we expect that crowding will negatively affect ED
length of stay at other types of EDs if they experience frequent
periods of crowding, as did the EDs in this study.
DISCUSSION
To our knowledge, this is the first study to measure
crowding dynamically and to examine its effect on ED length
of stay. We found that crowding was associated with
substantial delays in ED length of stay across 4 ED sites.
Moreover, crowding prolonged the ED length of stay of
high-acuity level 2 patients. Output factors, such as the
number of patients boarding and the inpatient medicine
occupancy rate, were associated with large delays in ED care.
Crowding negatively affected ED patients’ waiting room
time and boarding time but not treatment time. Some sites
were more sensitive to crowding than others. The results of
our study suggest that crowding has a negative effect on the
timeliness of the delivery of emergency care; however, the
magnitude of the effect varied by the crowding measure, the
phase of ED care, patient characteristics, and site.
During patients’ ED stay, the factor most consistently
associated with delays in ED care was the number of
boarders in the ED. Not only did the number of boarders
significantly increase ED patients’ boarding time but it also
substantially delayed their waiting room time. After adjusting
for the number of boarders in the ED, the inpatient
medicine occupancy rate was also associated with significant
delays in boarding time across the 4 sites. There is a
widespread misconception among the public, policymakers,
and the lay press that crowding is primarily caused by large
influxes of patient arrivals to the ED, particularly among the
Volume , .  : October 
Crowding and Length of Stay
uninsured or the poor27; however, the results of this study
and others clearly show that output factors are associated
with the biggest delays in emergency care.4,5,28,29
Among the ED patients admitted during weekdays, 58%
experienced a boarding time that was longer than their treatment
time (range across sites 45% to 78%). Patients boarding in the ED
for prolonged periods negatively affect patient flow in the ED. Each
boarder is equivalent to the loss of 1 ED treatment space and, more
important, the ED staff time associated with patient care, family
communication, and documentation requirements for an inpatient.
In this study, during normal periods, the median number of
boarders in the study EDs ranged from 5 to 13, which represents a
reduction in main ED bed capacity of 16% to 33%, depending on
the study site. When the bed capacity of an ED is routinely reduced
by boarders, it signifies a critical problem elsewhere in the system.
In this case, a boarding problem most likely reflects a resource
constraint (ie, inadequate inpatient bed capacity) or a policy
constraint (eg, bed management policies, financial incentives to
prioritize elective admissions over emergency ones). The results
of this study suggest that we must take a system-wide approach
to solve crowding; we cannot limit our analyses and changes
to the ED.
Proportionately, crowding affected ED waiting room time
the most across the 4 sites. ED waiting room time is the
shortest of the 3 phases of emergency care, so one could
misconstrue that decreasing waiting room time is the least
important. However, the ED is the front door of the hospital
to almost half of all patients admitted (42%).17 It is during
the waiting room time that ED patients and their families
form their first impressions of the facility. A number of
studies have found that prolonged wait time is associated
with patient dissatisfaction and an unwillingness to return to
the same facility or to recommend it to others.30-33 Thus, it
is critical that EDs keep waiting room times to a minimum
(experts recommend no more than 15 minutes without an
explanation for the delay) and develop strategies (eg,
frequent communication about delays, providing
information on how the ED works, offering comforts in the
waiting area) to make patients’ waiting room time as short
and pleasant as possible.34-36
Crowding had little effect on ED treatment time across all of
the study sites, regardless of the shift. These results suggest that
ED providers base their clinical decisions on patient and clinical
(ie, results of tests) characteristics rather than system factors.
Asaro et al5 also found at their institution that treatment time
was strongly influenced by patient demographic and clinical
characteristics and not crowding factors. Similarly, Forster et
al37 reported that ED admission rates did not vary significantly
by hospital occupancy level. These findings imply that any
substantial reductions in the ED treatment phase will be related
to improvement initiatives or technological advances in the
diagnostic, treatment, or discharge process, rather than better
management of patient flow.38,39
Annals of Emergency Medicine 501
Crowding and Length of Stay
Triage did not adequately protect severely ill patients
from delays in care during periods of crowding. Across all of
the sites, the wait time and boarding time of high-acuity
level 2 patients increased substantially during crowded
periods. These results are consistent with those of other
studies that have found that crowding causes delays in
emergency care for patients with time-sensitive conditions.11-13
It may be that EDs need to consider alternative prioritization
of patients such as the See-and-Treat approach being
adopted in the United Kingdom that divides patients into
those likely to be discharged versus admitted40-42 or a
manufacturing strategy that categorize patients by their
expected treatment rather than reported symptoms or
acuity.43
There was substantial variation in how crowding affected
the study EDs. A sample size of 4 facilities is too small to
draw any conclusions about how structural, procedural, or
cultural characteristics may contribute to crowding, but the
following qualitative observations are worth noting. First, the
waiting room time during normal periods at 2 of the EDs
was approximately equivalent to the waiting room time
during crowded periods at the other study sites. These long
waiting room times during normal periods most likely reflect
inefficient operations or inadequate capacity. Second, the 2
EDs with the shortest waiting room times during normal
periods were disproportionately affected by crowding. At
these 2 EDs, the number of boarders was associated with
bigger increases in boarding time (23% to 179% across the
shifts) compared with that of the other EDs (5% to 18%
across the shifts). Third, the ED with the worst boarding
problem had the most treatment spaces in the main ED but
lacked an observation unit. Finally, the 2 sites where
crowding affected the boarding times the most relied on
inpatient physicians to be responsible for ED boarders. These
results suggest that individual organizations face different
problems, so each facility should conduct a local assessment
to determine the best solutions to its crowding problem. In
addition, if EDs in the United States collected a uniform
minimum data set with standard data definitions, we could
more easily make across-facility comparisons and identify
best practices.
In summary, we have used a discrete-time survival analysis
approach to demonstrate the negative effect that crowding
has on the timely delivery of emergency care, even among
high-acuity patients. As the evidence of the deleterious
effects of crowding on patient care and outcomes continues
to accumulate, the federal government may need to step in as
it did in the United Kingdom and set a standard of care that
requires 98% of all ED patients be treated and discharged,
admitted, or transferred within 4 hours of presentation. It is
our belief that without major changes in our health care
delivery system, such as those undertaken in the United
Kingdom, EDs in the United States will continue to struggle
with crowding and its negative effect on patient care.40
502 Annals of Emergency Medicine
McCarthy et al
The authors would like to thank Allison Orlina, JD, for her help
obtaining the inpatient medicine occupancy rate data for one of the
study sites.
Supervising editor: Donald M. Yealy, MD
Author contributions: All of the authors were involved in the
study concept and design, drafting of the article, and critical
revision of the article for important intellectual content. The
objectives, data collection protocol, review of the analysis,
and findings were discussed by teleconference calls with all of
the investigators. MLM, JSD, JL, and DA were responsible for
acquiring the data from their sites and obtaining institutional
review board approval. RD performed the data analysis under
the supervision of MLM and SLZ. However, all of the authors
had input into the variables considered for the analysis and
how it was conducted. MLM drafted the article, and all
authors contributed substantially to its revision. MLM takes
responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required
to disclose any and all commercial, financial, and other
relationships in any way related to the subject of this article
that might create any potential conflict of interest. The authors
have stated that no such relationships exist. See the
Manuscript Submission Agreement in this issue for examples
of specific conflicts covered by this statement.
Earn CME Credit: Continuing Medical Education is available for
this article at: www.ACEP-EMedHome.com.
Publication dates: Received for publication January 14, 2009.
Revision received February 25, 2009. Accepted for publication
March 3, 2009. Available online May 6, 2009.
Address for reprints: Melissa L. McCarthy, ScD, 5801 Smith
Avenue, Davis Building Suite 3220, Department of Emergency
Medicine, Baltimore, MD 21209; 410-735-6421, fax 410-735-
6425; E-mail mmccarth@jhmi.edu.
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Annals of Emergency Medicine 503
Table E1. Impact of crowding on adjusted median times in minutes using discrete-time survival analysis models stratified by shift
†
and site for weekend visits only.*
8 AM To 4 PM 4 PM To Midnight Midnight to 8 AM

Site Site Site Site Site Site Site Site Site Site Site Site
Crowding Factors A B C D A B C D A B C D
Waiting room time
‡
Median 70 26 28 68 91 87 55 113 47 15 12 29
No. waiting, 90% 101 54 73 112 115 157 132 161 67 32 18 63
Pts. being treated, 90% 78 41 46 76 99 108 89 126 57 23 17 37
No. boarding, 90% 74 33 50 82 98 104 96 137 48 20 18 41
Treatment time
‡
Median 258 284 224 201 184 248 193 200 219 258 210 208
Pts. being treated, 90% 278 289 219 205 195 261 205 213 240 282 215 234
No. boarding, 90% 241 274 214 196 183 252 198 203 220 258 220 219
Inpatient medicine, 90% 264 296 240 205 186 249 195 201 223 258 214 211
Boarding time
‡
Median 250 334 626 334 192 157 288 378 162 125 347 289
No. boarding, 90% 288 410 921 395 208 208 501 420 170 187 967 338
Inpatient medicine, 90% 277 454 896 354 196 159 319 397 169 136 566 314
*Predictions were calculated for patients who visited the EDs on the weekends and were between 35 and 54 years old, were female, had commercial insurance cover-
age, walked in, and had acuity level 3, with a chief complaint of general symptoms.
†
Bolded values are statistically significant (P⬍.05).
‡
All crowding factors estimated at median level.

Table E2. Impact of crowding on adjusted median times in minutes using discrete-time survival analysis models stratified by shift
†
and site with unimputed data only.*
8 AM To 4 PM 4 PM To Midnight Midnight to 8 AM

Site Site Site Site Site Site Site Site Site

Crowding Factors A B C A B C A B C
Waiting room time
‡
Median 66 24 26 90 89 51 43 15 12
No. waiting, 90% 98 59 76 120 175 141 68 37 20
Pts. being treated, 90% 74 38 42 95 104 72 53 22 16
No. boarding, 90% 71 32 48 98 109 83 45 19 18
Treatment time
‡
Median 258 289 230 196 251 198 224 260 217
Pts. being treated, 90% 275 296 224 206 260 208 246 282 221
No. boarding, 90% 244 279 221 194 254 204 226 261 228
Inpatient medicine, 90% 265 300 247 200 252 199 227 260 220
Boarding time
‡
Median 244 353 728 192 157 288 159 123 389
No. boarding, 90% 291 442 1082 213 204 537 174 180 1072
Inpatient medicine, 90% 272 494 1013 198 159 322 167 131 656
*Predictions were calculated for patients who were between 35 and 54 years old, were female, had commercial insurance coverage, walked in, and had acuity level 3,
with a chief complaint of general symptoms.
†
Bolded values are statistically significant (P⬍.05).
‡
All crowding factors estimated at median level.

503.e1 Annals of Emergency Medicine Volume , .  : October 

 Figure E1. Sample R code to predict median time to completion of ED care.

Volume , .  : October  Annals of Emergency Medicine 503.e2

 Figure E1. (Cont’d)

503.e3 Annals of Emergency Medicine Volume , .  : October 

 Figure E1. (Cont’d)

Volume , .  : October  Annals of Emergency Medicine 503.e4