Date of Award

January 2024

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)



First Advisor

Monisha Dilip


Aims:Pooling inpatient bed resources for more efficient bed management is a promising solution to the pervasive problem of Emergency Department crowding. This study aims to characterize a regionalization protocol in place for ED-to-inpatient disposition between a tertiary academic medical center (AMC) and an urban community teaching hospital in an integrated health system, overseen by a single Bed Management Department. An additional purpose of this study is to investigate transfer decisions from a health equity perspective.

Methods:This is a retrospective observational study utilizing electronic admissions records from the two hospitals’ Emergency Departments to general medicine floors between January 1, 2020 and December 31, 2020. ED length of stay (LOS), hospital length of stay, acuity level, and demographic characteristics of patients admitted to the academic medical center and those admitted to the neighboring community hospital were assessed by linear regression.

Results:In the study period, 11,847 patients were admitted from the AMC ED to general medicine services. No differences were found between transferred vs. not transferred patients in terms of acuity, race/ethnicity, or primary language. Patients age >80, female, insured by Medicare or Medicaid, and uninsured were transferred at higher rates. Both mean ED LOS and hospital LOS were statistically significantly shorter for patients transferred to the community hospital compared to those admitted to the AMC. Among patients transferred, the most common chief complaint categories were respiratory symptoms, abdominal symptoms, and focal neurologic symptoms. Patients admitted to the community hospital directly from its own ED experienced shorter ED LOS but longer overall hospital LOS than those transferred from the AMC.

Conclusions:Transfers upon admission from an academic medical center ED to a community teaching hospital are feasible in a large proportion of presenting patients. Transferred patients experience lower levels of ED crowding, as measured by ED LOS, and shorter hospital LOS compared to their AMC-admitted counterparts. In implementing a regionalization strategy, financial incentive alignment, risks and benefits of hospital consolidation, and compliance with EMTALA are important considerations.


This is an Open Access Thesis.

Open Access

This Article is Open Access