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Peer-reviewedCC BY 4.0Health Science Reports

Emergency Department Boarding and Mortality: A Systematic Review and Proportional Meta‐Analysis

  • Gerardo Altamura1
  • Mario Cesare Nurchis2,3
  • Silvia Martinelli2
  • Annarita Panebianco1
  • Gabriele Giubbini4
  • Marcello Covino5
  • Francesco Franceschi5
  • Gianfranco Damiani2,3
5 affiliations
  1. 1Medical Management, IDI‐IRCCS ‐ FLMM Rome Italy
  2. 2Department of Health Sciences and Public Health Section of Hygiene, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1 Rome Italy
  3. 3Department of Woman and Child Health and Public Health Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome Italy
  4. 4Health Management, Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome Italy
  5. 5Emergency Medicine Department Fondazione Policlinico Universitario Agostino Gemelli‐IRCCS, Università Cattolica del Sacro Cuore di Roma, Largo A. Gemelli 8 Rome Italy
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Abstract

Background and Aims: Emergency department (ED) crowding, worsened by ED boarding (EDB), is defined as the stay of admitted patients in the emergency department due to the unavailability of inpatient beds. This occurrence poses a significant public health challenge, leading to adverse patient outcomes. Despite efforts to improve patient care pathways, the relationship between EDB and mortality is still contentious. This study aims to synthesize and compare reported in‐hospital mortality (IHM) among ED patients across studies stratified by ED boarding duration thresholds, with particular attention to shorter boarding durations.

Methods: A systematic review and proportional meta‐analysis were conducted following PRISMA guidelines. MEDLINE, EMBASE, Web of Science, and Scopus were searched up to April 2024. Pooled mortality proportions were estimated using random‐effects models with DerSimonian–Laird estimation and Freeman–Tukey double arcsine transformation. Heterogeneity was assessed using I2. Leave‐one‐out analyses were performed to assess the robustness of subgroup estimates, with particular attention to longer boarding thresholds.

Results: Twenty studies published between 2007 and 2024 were included. The overall pooled in‐hospital mortality proportion was 8.3% (95% CI: 7.6%–9.0%; I2 = 99.9%). Subgroup analyses showed pooled mortality estimates of 10.2% for early admission/no boarding, 4.4% for 1‐h boarding, 5.9% for 2‐h boarding, 4.8% for 4‐h boarding, 13.5% for 6‐h boarding, 20.5% for 8‐h boarding, 21.8% for 12‐h boarding, and 11.8% for 24‐h boarding. Shorter boarding thresholds were not associated with higher pooled mortality estimates compared with early admission/no boarding. Although longer boarding thresholds showed higher pooled mortality estimates, the 8‐, 12‐, and 24‐h subgroup estimates were based on few studies and were materially influenced by Verma et al. 2021. After excluding this study, the pooled mortality estimates decreased to 7.9%, 3.9%, and 4.0% for the 8‐, 12‐, and 24‐h subgroups, respectively. Given the extreme heterogeneity, these pooled estimates require cautious interpretation. Because different studies contributed to different threshold‐specific pools, the estimates are descriptive and should not be interpreted as evidence of a threshold or dose‐response relationship.

Conclusion: This study highlights the possible association between prompt admissions, targeted interventions, and outcomes in the context of ED boarding. Improving ED operations and reducing boarding times within these durations remain important organizational objectives. Further research with standardized methodologies is essential to fully understand and address this complex issue. However, the present pooled proportions do not establish a boarding‐duration threshold, dose‐response relationship, or causal association, and their interpretation is limited by extreme heterogeneity (I2 = 99.9%).

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Cite

BibTeXRIS
BibTeX
@article{altamura2026emergency,
  title = {{Emergency Department Boarding and Mortality: A Systematic Review and Proportional Meta‐Analysis}},
  author = {Gerardo Altamura and Mario Cesare Nurchis and Silvia Martinelli and Annarita Panebianco and Gabriele Giubbini and Marcello Covino and Francesco Franceschi and Gianfranco Damiani},
  journal = {Health Science Reports},
  year = {2026},
  month = nov,
  doi = {10.1002/hsr2.73400},
  url = {https://doi.org/10.1002/hsr2.73400},
  note = {CC BY 4.0},
}
RIS
TY  - JOUR
TI  - Emergency Department Boarding and Mortality: A Systematic Review and Proportional Meta‐Analysis
AU  - Gerardo Altamura
AU  - Mario Cesare Nurchis
AU  - Silvia Martinelli
AU  - Annarita Panebianco
AU  - Gabriele Giubbini
AU  - Marcello Covino
AU  - Francesco Franceschi
AU  - Gianfranco Damiani
PY  - 2026
DA  - 2026/11/04
JO  - Health Science Reports
DO  - 10.1002/hsr2.73400
UR  - https://doi.org/10.1002/hsr2.73400
AB  - Background and Aims: Emergency department (ED) crowding, worsened by ED boarding (EDB), is defined as the stay of admitted patients in the emergency department due to the unavailability of inpatient beds. This occurrence poses a significant public health challenge, leading to adverse patient outcomes. Despite efforts to improve patient care pathways, the relationship between EDB and mortality is still contentious. This study aims to synthesize and compare reported in‐hospital mortality (IHM) among ED patients across studies stratified by ED boarding duration thresholds, with particular attention to shorter boarding durations.  Methods: A systematic review and proportional meta‐analysis were conducted following PRISMA guidelines. MEDLINE, EMBASE, Web of Science, and Scopus were searched up to April 2024. Pooled mortality proportions were estimated using random‐effects models with DerSimonian–Laird estimation and Freeman–Tukey double arcsine transformation. Heterogeneity was assessed using I2. Leave‐one‐out analyses were performed to assess the robustness of subgroup estimates, with particular attention to longer boarding thresholds.  Results: Twenty studies published between 2007 and 2024 were included. The overall pooled in‐hospital mortality proportion was 8.3% (95% CI: 7.6%–9.0%; I2 = 99.9%). Subgroup analyses showed pooled mortality estimates of 10.2% for early admission/no boarding, 4.4% for 1‐h boarding, 5.9% for 2‐h boarding, 4.8% for 4‐h boarding, 13.5% for 6‐h boarding, 20.5% for 8‐h boarding, 21.8% for 12‐h boarding, and 11.8% for 24‐h boarding. Shorter boarding thresholds were not associated with higher pooled mortality estimates compared with early admission/no boarding. Although longer boarding thresholds showed higher pooled mortality estimates, the 8‐, 12‐, and 24‐h subgroup estimates were based on few studies and were materially influenced by Verma et al. 2021. After excluding this study, the pooled mortality estimates decreased to 7.9%, 3.9%, and 4.0% for the 8‐, 12‐, and 24‐h subgroups, respectively. Given the extreme heterogeneity, these pooled estimates require cautious interpretation. Because different studies contributed to different threshold‐specific pools, the estimates are descriptive and should not be interpreted as evidence of a threshold or dose‐response relationship.  Conclusion: This study highlights the possible association between prompt admissions, targeted interventions, and outcomes in the context of ED boarding. Improving ED operations and reducing boarding times within these durations remain important organizational objectives. Further research with standardized methodologies is essential to fully understand and address this complex issue. However, the present pooled proportions do not establish a boarding‐duration threshold, dose‐response relationship, or causal association, and their interpretation is limited by extreme heterogeneity (I2 = 99.9%).
SN  - 2398-8835
ER  -