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Acad Emerg Med. 2012 Jul;19(7):816-20. doi: 10.1111/j.1553-2712.2012.01390.x. Epub 2012 Jun 22.

Pediatric emergency department crowding is associated with a lower likelihood of hospital admission.

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Division of Emergency Medicine, Children's Hospital Boston, Boston, MA, USA.



Emergency department (ED) crowding may affect disposition decision-making. The objective was to measure the effect of ED crowding on probability of admission and return visit to the ED after discharge.


The authors studied a historical cohort at a large pediatric ED over 40 months. Each patient was assigned a score on arrival based on the ED occupancy rate (the ratio of patients to beds). Patients were divided into quintiles by occupancy rate. The proportion admitted for each quintile was compared to the least crowded quintile adjusting for acuity, hospital occupancy, and time of arrival. The same analysis was performed for return visits to the ED within 48 hours. The analyses were repeated for the subsets of patients with asthma and with gastroenteritis and/or dehydration.


From the 40 months of historical data, 198,778 visits were analyzed. The adjusted odds ratio (aOR) for admission among the whole cohort was 0.85 (95% confidence interval [CI]=0.81 to 0.89) comparing the highest to the lowest crowding quintiles (occupancy rate >1.17 and <0.54, respectively). For asthma patients, aOR=0.93 (95% CI=0.72 to 1.20), and for gastroenteritis patients, aOR=0.87 (95% CI=0.65 to 1.17). The aOR of return visits comparing the highest to the lowest crowding quintiles for all patients was aOR=0.87 (95% CI=0.79 to 0.97), for asthma patients was aOR=1.52 (95% CI=0.95 to 2.46), and for gastroenteritis patients was aOR=0.83 (95% CI=0.54 to 1.28).


Increasing ED crowding is associated with a lower likelihood of hospital admission and lower frequency of return visits within 48 hours.

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