Bed-to-Bed Transfer Program Among Patients Who Need Hospitalization in a Crowded Emergency Department in Taiwan

Document Type : Original Article


1 School of Nursing, National Taiwan University, Taipei, Taiwan

2 Department of Emergency, National Taiwan University Hospital, Taipei, Taiwan

3 Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan

4 Institute of Clinical Nursing, College of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan


Emergency department (ED) crowding is a universal issue. In Taiwan, patients with common medical problems prefer to visit ED of medical centers, resulting in overcrowding. Thus, a bed- to-bed transfer program has been implemented since 2014. However, there was few studies that compared clinical outcomes among patients who choose to stay in medical centers to those being transferred to regional hospitals. The aim of this study was to explore the transfer rate, delineate the factors related to patient transfer, and clarify the influence upon the program outcomes.

A retrospective cohort study was conducted using demographic and clinical disease factors from the patient electronic referral system, electronic medical records (EMRs) of a medical center in Taipei, and response to referrals from regional hospitals. The study included adult patients who were assessed as appropriate for transfer in 2016. We analyzed the outcomes (length of stay and mortality rate) between the referrals were accepted and refused using propensity score matching.

Of the 1759 patients eligible for transfer to regional hospitals, 420 patients (24%) accepted the referral. Medical records were obtained from the regional hospitals for 283 patients (67%). After propensity score matching, the results showed that interhospital transfer resulted in similar median total length of stay (8.7 days in the medical center vs 7.9 days in regional hospitals; P = .245). In-hospital mortality was low for both groups (3.1% in the medical center vs 1.3% in regional hospitals; P = .344).

Transfer from an overcrowded ED in a medical center to regional hospitals in eligible patients results in non-significant outcome of total length of stay. With the caveat of an underpowered sample, we did not find statistically significant differences in in-hospital mortality. This healthcare delivery model may be used in other cities facing similar problems of ED overcrowding.


  1. Salehi L, Phalpher P, Valani R, et al. Emergency department boarding: a descriptive analysis and measurement of impact on outcomes. CJEM. 2018;20(6):929-937. doi:10.1017/cem.2018.18
  2. Pines JM, Hilton JA, Weber EJ, et al. International perspectives on emergency department crowding. Acad Emerg Med. 2011;18(12):1358-1370. doi:10.1111/j.1553-2712.2011.01235.x
  3. Patel PB, Combs MA, Vinson DR. Reduction of admit wait times: the effect of a leadership-based program. Acad Emerg Med. 2014;21(3):266-273. doi:10.1111/acem.12327
  4. McCarthy ML, Ding R, Pines JM, Zeger SL. Comparison of methods for measuring crowding and its effects on length of stay in the emergency department. Acad Emerg Med. 2011;18(12):1269-1277. doi:10.1111/j.1553-2712.2011.01232.x
  5. Bittencourt RJ, Stevanato AM, Bragança C, Gottems LBD, O'Dwyer G. Interventions in overcrowding of emergency departments: an overview of systematic reviews. Rev Saude Publica. 2020;54:66. doi:10.11606/s1518-8787.2020054002342
  6. Li M, Vanberkel P, Carter AJE. A review on ambulance offload delay literature. Health Care Manag Sci. 2019;22(4):658-675. doi:10.1007/s10729-018-9450-x
  7. van der Linden MC, Meester BE, van der Linden N. Emergency department crowding affects triage processes. Int Emerg Nurs. 2016;29:27-31. doi:10.1016/j.ienj.2016.02.003
  8. Beltrán Guzmán I, Gil Cuesta J, Trelles M, et al. Delays in arrival and treatment in emergency departments: women, children and non-trauma consultations the most at risk in humanitarian settings. PLoS One. 2019;14(3):e0213362. doi:10.1371/journal.pone.0213362
  9. Chang YH, Shih HM, Chen CY, Chen WK, Huang FW, Muo CH. Association of sudden in-hospital cardiac arrest with emergency department crowding. Resuscitation. 2019;138:106-109. doi:10.1016/j.resuscitation.2019.03.001
  10. Kim JS, Bae HJ, Sohn CH, et al. Maximum emergency department overcrowding is correlated with occurrence of unexpected cardiac arrest. Crit Care. 2020;24(1):305. doi:10.1186/s13054-020-03019-w
  11. Chiang WT, Li WH, Liao CC. Emergency department overcrowding in Taiwan. Fu-Jen Journal of Medicine. 2015;13(4):223-231. doi:10.3966/181020932015121304007
  12. Hsu CM, Liang LL, Chang YT, Juang WC. Emergency department overcrowding: quality improvement in a Taiwan Medical Center. J Formos Med Assoc. 2019;118(1 Pt 1):186-193. doi:10.1016/j.jfma.2018.03.008
  13. Yu SM, Chan SY, Chu D, Chen YT. The quantity and satisfaction report of policy implementation of a single regional hospital receiving patient referred from the Taipei City medical center emergency department. Taipei City Medical Journal. 2017;14(2):171-177. doi:10.6200/tcmj.2017.14.2.05
  14. Hill AD, Fowler RA, Nathens AB. Impact of interhospital transfer on outcomes for trauma patients: a systematic review. J Trauma. 2011;71(6):1885-1900. doi:10.1097/TA.0b013e31823ac642
  15. Holland CM, Lovasik BP, Howard BM, McClure EW, Samuels OB, Barrow DL. Interhospital transfer of neurosurgical patients: implications of timing on hospital course and clinical outcomes. Neurosurgery. 2017;81(3):450-457. doi:10.1093/neuros/nyw124
  16. Rush B, Tyler PD, Stone DJ, Geisler BP, Walley KR, Celi LA. Outcomes of ventilated patients with sepsis who undergo interhospital transfer: a nationwide linked analysis. Crit Care Med. 2018;46(1):e81-e86. doi:10.1097/ccm.0000000000002777
  17. Sonig A, Lin N, Krishna C, et al. Impact of transfer status on hospitalization cost and discharge disposition for acute ischemic stroke across the US. J Neurosurg. 2016;124(5):1228-1237. doi:10.3171/2015.4.jns141631
  18. Tsai JC, Tsai YT, Weng SJ, Liu SC. Emergency department overcrowding: an overview of critical issues and improvement strategies. Taiwan J Public Health. 2021;40(1):8-29. doi:10.6288/tjph.202102_40(1).109124
  19. Castillo-Angeles M, Uribe-Leitz T, Jarman M, et al. Transferred emergency general surgery patients are at increased risk of death: a NSQIP propensity score matched analysis. J Am Coll Surg. 2019;228(6):871-877. doi:10.1016/j.jamcollsurg.2019.01.014
  20. Nickles AV, Roberts S, Shell E, et al. Characteristics and outcomes of stroke patients transferred to hospitals participating in the Michigan Coverdell Acute Stroke Registry. Circ Cardiovasc Qual Outcomes. 2016;9(3):265-274. doi:10.1161/circoutcomes.115.002388
  21. Austin PC. An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivariate Behav Res. 2011;46(3):399-424. doi:10.1080/00273171.2011.568786
  22. Trutschel D, Palm R, Holle B, Simon M. Methodological approaches in analysing observational data: a practical example on how to address clustering and selection bias. Int J Nurs Stud. 2017;76:36-44. doi:10.1016/j.ijnurstu.2017.06.017
  23. Chang CC, Chen WM, Chen CF, Wu SC. Impact of chronic kidney disease on outcome of total hip replacement patients. Taiwan J Public Health. 2016;35(1):53-65. doi:10.6288/tjph201635104066
  24. Frost SA, Alexandrou E, Bogdanovski T, Salamonson Y, Parr MJ, Hillman KM. Unplanned admission to intensive care after emergency hospitalisation: risk factors and development of a nomogram for individualising risk. Resuscitation. 2009;80(2):224-230. doi:10.1016/j.resuscitation.2008.10.030
  25. Tan C, Ng YS, Koh GC, De Silva DA, Earnest A, Barbier S. Disability impacts length of stay in general internal medicine patients. J Gen Intern Med. 2014;29(6):885-890. doi:10.1007/s11606-014-2815-z
  26. Tam V, Frost SA, Hillman KM, Salamonson Y. Using administrative data to develop a nomogram for individualising risk of unplanned admission to intensive care. Resuscitation. 2008;79(2):241-248. doi:10.1016/j.resuscitation.2008.06.023
  27. Austin PC. Optimal caliper widths for propensity-score matching when estimating differences in means and differences in proportions in observational studies. Pharm Stat. 2011;10(2):150-161. doi:10.1002/pst.433
  28. Wang Y, Cai H, Li C, et al. Optimal caliper width for propensity score matching of three treatment groups: a Monte Carlo study. PLoS One. 2013;8(12):e81045. doi:10.1371/journal.pone.0081045
  29. Austin PC. Assessing balance in measured baseline covariates when using many-to-one matching on the propensity-score. Pharmacoepidemiol Drug Saf. 2008;17(12):1218-1225. doi:10.1002/pds.1674
  30. Stuart EA. Matching methods for causal inference: a review and a look forward. Stat Sci. 2010;25(1):1-21. doi:10.1214/09-sts313
  31. Li JY, Lin JW, Wu ZH, Wu HW, Yeh CC, Yang YW. A study on the characteristics and medical resource utilization of patients with chronic obstructive pulmonary disease. J Healthc Manag. 2008;9(3):159-173. doi:10.6174/jhm2008.9(3).159
  32. Chiu HY, Cheng SH, Tung YC. Associations of continuity and level with outcomes and expenses of post-discharge care for patients with heart failure. Taiwan J Public Health. 2016;35(1):66-79. doi:10.6288/tjph201635104065
  33. Ahn JY, Ryoo HW, Park J, et al. New intervention model of regional transfer network system to alleviate crowding of regional emergency medical center. J Korean Med Sci. 2016;31(5):806-813. doi:10.3346/jkms.2016.31.5.806
  34. Russell P, Hakendorf P, Thompson C. Inter-hospital lateral transfer does not increase length of stay. Aust Health Rev. 2015;39(4):400-403. doi:10.1071/ah14216
  35. Mueller S, Zheng J, Orav EJ, Schnipper JL. Inter-hospital transfer and patient outcomes: a retrospective cohort study. BMJ Qual Saf. 2019;28(11):e1. doi:10.1136/bmjqs-2018-008087
  36. Kreindler SA, Cui Y, Metge CJ, Raynard M. Patient characteristics associated with longer emergency department stay: a rapid review. Emerg Med J. 2016;33(3):194-199. doi:10.1136/emermed-2015-204913
Volume 11, Issue 9
September 2022
Pages 1844-1851
  • Receive Date: 21 July 2020
  • Revise Date: 25 May 2021
  • Accept Date: 18 July 2021
  • First Publish Date: 24 August 2021