Crowding in the ED has been well-established as a problem that poses a threat to public health. Studies show that ED and hospital crowding leads to ambulance diversions, medical errors, delayed care, and increased mortality rates. “Many strategies have been tried to alleviate ED and hospital crowding, some of which involve the entire institution,” explains Peter Viccellio, MD.

Using a Full-Capacity Protocol

One strategy that aims to reduce ED crowding is the use of a full-capacity protocol (FCP), in which admitted ED patients are redistributed to inpatient unit hallways while they wait for regular hospital beds to open up. Some studies have shown that an FCP can decrease ED wait times, ambulance diversions, and overall hospital length of stay. A potential concern with this approach, however, is that it could reduce patient satisfaction.

Recently, Dr. Viccellio and colleagues had a study published in the Journal of Emergency Medicine that examined patient preference and satisfaction with boarding in the ED versus inpatient hallways during times when there were no inpatient beds available for admitted patients. All patients were initially boarded in the ED in a hallway before their transfer to an inpatient hallway bed. “No more than two patients in our study were placed on any inpatient unit and all patients received direct care from inpatient physicians and nurse specialists,” adds Dr. Viccellio. “We didn’t compare a room versus a hallway. Rather, we looked at making decisions about where patients can receive the best care and greatest attention in difficult circumstances when a normal room is not available.”


Overwhelming Results

According to the results, the overall preferred location after admission was the inpatient hallway in 85% of the 105 respondents involved in the analysis. When comparing hallway boarding types, most respondents preferred inpatient boarding with regard to rest, safety, confidentiality, treatment, comfort, quiet, staff availability, and privacy. For no item assessed in the study was there a preference for boarding in the ED. “Patients overwhelmingly preferred the inpatient hallway to the ED hallway,” says Dr. Viccellio. “Furthermore, the FCP strategy decreased length of stay by about 1 day and didn’t compromise safety.” In addition, ED patients were willing to be moved out of their ED rooms after being seen so that other patients could be seen.

Dr. Viccellio says that an FCP is not a “cure all” to ED crowding but does improve patient flow, helps with length of stay, and appears to be safe. “Decreasing boarding of admitted ED patients can lead to many desirable patient safety outcomes,” he says. “Our study lends further support to implementing an FCP since patients overwhelmingly preferred to be boarded on inpatient hallways than ED hallways.”


Viccellio P, Zito JA, Sayage V, et al. Patients overwhelmingly prefer inpatient boarding to emergency department boarding. J Emerg Med. 2013;45:942-946. Available at:

Viccellio A, Santora C, Singer AJ, Thode HC Jr, Henry MC. The association between transfer of emergency department boarders to inpatient hallways and mortality: a 4-year experience. Ann Emerg Med. 2009;54:487-491.

Pines JM, Yealy DM. Advancing the science of emergency department crowding: measurement and solutions. Ann Emerg Med. 2009;54:511-513.

Singer AJ, Thode HC Jr, Viccellio P, Pines JM. The association between length of emergency department boarding and mortality. Acad Emerg Med. 2011;18:1324-1329.

Walsh P, Cortez V, Bhakta H. Patients would prefer ward to emergency department boarding while awaiting an inpatient bed. J Emerg Med. 2008;34:221-226.