The epidemiology of emergency department crowding and boarding in Brazil: a nationwide multicenter study
This nationwide multicenter study reveals that emergency department crowding and boarding are pervasive structural challenges across Brazil, with occupancy routinely exceeding capacity and boarding affecting nearly half of patients, regardless of municipal socioeconomic development.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
In the bustling heart of a hospital, the emergency department serves as the front door for the sick and injured. It is a place designed for speed, where patients arrive with urgent needs and are meant to be seen, treated, and then moved on to the next stage of their care. However, when the flow of people entering the door outpaces the space available to treat them, a bottleneck forms. This phenomenon, known as crowding, happens when demand exceeds capacity. It is not merely a matter of long lines; it is a systemic strain that can delay life-saving treatments and compromise patient safety. A specific and critical part of this problem is "boarding." Boarding occurs when a doctor has already decided a patient needs to be admitted to the hospital, but there is no empty bed in the wards to receive them. Consequently, the patient remains stuck in the emergency room, occupying a spot meant for new arrivals, while waiting for a bed that may not open for days. This creates a logjam where the emergency room becomes a holding area rather than a place of acute care.
Researchers in Brazil recently set out to understand the true scale of this crisis across their entire nation. While emergency room crowding is a known issue in wealthy countries, its patterns in lower-income nations were less clear. The team, drawing data from 160 hospitals that participated in a national quality improvement program, analyzed operational records spanning from 2019 to 2025. They looked at two main things: how full the emergency rooms were compared to their official bed count, and what fraction of the people inside had already been admitted but were still waiting for a hospital bed. The study covered a vast geographic area, from the Amazon in the north to the southern states, and included both public and private hospitals that serve the public health system.
The findings reveal a system under constant, heavy pressure. The researchers found that, on average, emergency departments were operating beyond their formal capacity. For every designated treatment space, there was slightly more than one patient present. This means that at any given moment, these rooms were filled with people who did not have a dedicated bed, forcing staff to use hallways or temporary spaces to provide care. Even more striking was the situation regarding boarding. The data showed that nearly half of all patients present in these emergency rooms had already been admitted to the hospital but were still physically located in the emergency department. In other words, almost every two people in the room, one was waiting for a bed that was not available. This indicates that the primary bottleneck is not just too many people arriving, but a failure in the hospital's ability to move admitted patients out of the emergency room and into their proper wards.
The study also examined how these conditions changed over time and across different regions. During the early days of the global pandemic, when people were staying home and avoiding hospitals, the number of patients in emergency rooms dropped temporarily. However, once that period passed, the crowding returned to its previous high levels. In contrast, the problem of boarding remained stubbornly high throughout the entire seven-year period, showing no significant improvement despite ongoing efforts to fix the system. The researchers mapped these issues across Brazil and found that while there were some regional differences, high levels of crowding and boarding were widespread everywhere. The South and Southeast regions often saw very high occupancy, while the Northeast and Central-West showed significant spikes in certain years. The problem was not isolated to a few cities or specific types of hospitals; it affected small and large facilities, teaching and non-teaching centers, and both public and philanthropic institutions equally.
A key question the researchers asked was whether wealthier areas with better social conditions had less crowding. They looked at the human development of the towns where these hospitals were located, measuring factors like income, education, and life expectancy. Surprisingly, they found no clear link between a town's wealth and how crowded its emergency rooms were. Whether a municipality was rich or poor, the emergency rooms were just as likely to be full and full of boarded patients. The data suggested that the issue was not simply a lack of money in a community, but a structural problem within the healthcare system itself. When the researchers adjusted their analysis to account for the number of publicly funded beds available, the picture became clearer: the shortage of these specific beds seemed to be a major driver of the problem, regardless of the local economic status.
The implications of these findings are significant for how hospitals and governments approach emergency care. The study suggests that fixing the emergency room alone is not enough. Because the main issue is that admitted patients cannot leave the emergency room due to a lack of beds elsewhere in the hospital, solutions must focus on the entire hospital system. Improving how patients are discharged, increasing the number of available inpatient beds, and managing the flow of people through the whole hospital are likely more effective than just trying to speed up the triage process at the front door. The research confirms that emergency department crowding in Brazil is not a temporary glitch or a localized failure, but a persistent, nationwide structural challenge. It is a condition where the system is consistently running at or beyond its limit, requiring coordinated strategies that look beyond the emergency department walls to ensure patients can move through the system safely and efficiently.
Drowning in papers in your field?
Get daily digests of the most novel papers matching your research keywords — with technical summaries, in your language.