Emergency department boarding time and in‑hospital mortality: A prospective observational study

Abstract

OBJECTIVES: We aimed to study the association between prolonged boarding time in the emergency department (ED) and in hospital mortality among patients triaged red at presentation.

METHODS: It was a single center prospective observational study conducted among 300 patients who presented to the ED of a tertiary care teaching institute in North India. The boarding time was calculated as the time interval between the time at which the patient was advised admission and the time at which the patient was admitted to the indoor bed. Risk stratification of patients was done based on National Early Warning Score 2 (NEWS2) at presentation. The patient was then followed up for the duration of their in hospital course, till discharge or death.

RESULTS: The mean boarding time was higher in patients who died, as compared to those who were alive, but the difference was not found to be statistically significant (14.13 h vs. 11.89 h, P = 0.053). Boarding time had a weak discriminatory power on receiver operating characteristic (ROC) analysis (area under the ROC: 0.59: 95% confidence interval [CI]: 0.51–0.67, P = 0.046). A boarding time of more than 9.98 h was found to be 70.8% specific and 43.6% sensitive for predicting in hospital mortality. On logistic regression, an increase in boarding time was found to independently increase the odds of mortality, albeit weakly (adjusted odds ratio: 1.06; 95% CI: 1.00–1.12, P = 0.03). A NEWS2 score > 4 at presentation and a requirement of high dependency unit (HDU)/ıntensive care unit (ICU) admission were found to be significant predictors of in hospital mortality.

CONCLUSION: Prolonged ED boarding times may be weakly associated with in hospital mortality. Patients with an increased NEWS2 score at presentation and those requiring HDU/ICU admissions were at higher risk of in hospital mortality.

Introduction

Emergency department (ED) “boarding” of critically ill patients is the holding of patients who have been advised admission in the ED until an inpatient bed becomes available.[1] Prolonged ED boarding times directly result in ED overcrowding. Causes include high daily throughput, limitations in available infrastructure and human resources, and dearth of admission beds. Overcrowding of EDs has been globally identified as a significant challenge for healthcare systems and public health policy makers, impeding access to quality healthcare. The mean total waiting time for patients visiting the ED of a tertiary care hospital in India, from arrival until transfer to the admitting unit, was reported to be 2.46 h.[2]

The effects of overcrowding are manifold, affecting both patients and healthcare workers.[3] Patients have low satisfaction with care, suboptimal or delayed care, and most worrying of all increased mortality. Multiple studies demonstrate an association between increased length of stay, in hospital mortality, and requirement of intensive care unit (ICU) admission.[4,5]

ED overcrowding also results in delays in definitive treatment for life threatening time sensitive conditions such as myocardial infarction, higher complication rates in acute coronary syndrome (ACS) and non ACS related chest pain, and prolonged disposition times in patients with acute asthma.[6,7] Studies have reported an association between the number of boarding patients in the ED and delay in antibiotics and pain relief, as well as lower patient satisfaction.[8]

Despite these findings, the literature on the impact of ED boarding time on patient mortality shows mixed results.[9,10] These inconsistencies may stem from variations in study designs (often retrospective), differences in hospital protocols, and diverse patient populations. Notably, there is a lack of data regarding the same from resource limited healthcare systems such as those in India. This is potentially due to multiple reasons, including the relative infancy of emergency medicine as a specialty in many parts of the country, as well as possible underappreciation of boarding times as a concern to patient health and outcomes. In our literature search, we could not come across any studies that aimed to quantify or study this critical issue in an Indian healthcare setting. This study was hence conducted to examine the relationship between boarding times and in hospital mortality among the patients presenting to the ED of a tertiary care hospital in North India.

Material and Methods

Study design and setting

The study was conducted from September 2021 to February 2023, in the ED of a tertiary care teaching hospital in North India, with a yearly attendance of about 100,000 patients, of which around 2%– 5% patients are triaged red at presentation. This was a single center, prospective, observational study conducted after obtaining ethical approval from the ınstitute ethics committee of All India Institute of Medical Sciences, New Delhi (IECGP 551/ September 23, 2021).

Study population

We included patients aged over 14 years who presented to the ED and were triaged red (requiring immediate attention) as per institutional protocol.[11] They were sequentially recruited for the study after inpatient admission orders were received under a specific department following initial resuscitation and stabilization. We excluded patients who:

1. Presented to the ED following trauma

2. Were transferred to other hospitals following stabilization in ED

3. Had a cardiac arrest in the ED after admission was advised

4. Had ST elevation myocardial infarction or acute ischemic stroke at presentation and were taken up for immediate reperfusion therapy.

Sample size calculation

At the time of designing the study, we could not find any prospective studies evaluating the effect of ED boarding time on in hospital mortality in the then reviewed literature. Assuming an outcome prevalence of 50% and an effect size of 0.06, the sample size was calculated to be 267 using the Cochran formula. We intended to recruit 300 study participants to account for missing data as well as to counter a possibly higher Type II error.

Participant recruitment and management

All patients presenting to the ED underwent triage and initial care led by a team comprising trained emergency physicians and nursing staff. These were done as per institutional protocols and were not altered for the purpose of conduct of the study. Following stabilisation, red patients were either discharged or assigned admission under specific departments. Patients who were deemed critically ill even after initial resuscitation and stabilization in the ED were allotted ICU beds. Patients who had attained a certain degree of clinical stability in the ED but required intensive monitoring or were anticipated to have a clinical deterioration were allotted high dependency unit (HDU) beds. Patients who had improved following their ED stay and were reasonably expected to be free of imminent threats to life, but requiring admission, were shifted to the wards. All decisions were made by the treating team comprising ED physicians on duty as well as the primary admitting department, and were subject to the availability of inpatient beds. Patients were recruited after obtaining informed consent from the patient or their legally authorized representative. Data were collected using a predesigned questionnaire, consisting of demographic details, presenting symptoms of the patient, previous medical or surgical history, physical examination findings, and disposition details. Clinical data collected at the presentation of the patient were used to calculate National Early Warning Score 2 (NEWS2) and then stratify the patient according to the severity of illness [Table 1].[12]

Table 1. Clinical risk stratification based on National Early Warning Score 2 score

The time at which the patient was advised admission was noted as T₀ . The time at which the patient was admitted to the hospital inpatient bed was noted as T₁ . The boarding time was calculated as the difference between T₁ and T₀. The patient was then followed up for the duration of their in hospital course, till discharge or death.

Statistical analysis

Data were collected in Microsoft Excel (Microsoft Corporation, 2018), and all statistical analyses were done with IBM SPSS Statistics for Windows (version 25.0, Released 2020, IBM Corp., Armonk, NY, USA). Quantitative variables were presented as mean with standard deviation for normally distributed data and as median with interquartile range, otherwise. Qualitative variables were expressed as counts and percentages. Mean values were compared across groups by ındependent samples t test or Mann–Whitney U test where applicable. Percentages were compared across groups by Chi square or Kruskal–Wallis tests as appropriate. The receiver operating characteristic (ROC) curve was used to assess the accuracy of boarding time in predicting mortality and to determine valid cutoffs. Logistic regression (LR) was used to identify the predictors of in hospital mortality, where covariates included age, sex, clinical risk stratification according to NEWS2 score, boarding time, and the unit of admission. All missing data were excluded from the data analysis. A post hoc subgroup analysis was done wherein the patient population was divided into subgroups based on the unit of admittance. LR was used to study the association between boarding time and mortality. Statistical significance was set at a two tailed P < 0.05.

Results

We screened 1982 patients triaged red in our emergency for the purpose of this study. Four hundred sixty five patients were discharged from the ED, and 1152 patients were referred to other hospitals (mostly due to shortage of inpatient beds) following initial resuscitation and stabilization. We considered 365 patients for inclusion in the study after they were advised admission by a specialty department. Fifty two patients were excluded: 29 were transferred to other hospitals as inpatient beds could not be arranged despite advice, 21 patients experienced cardiac arrest after admission was advised, and 2 had a history of trauma at presentation. Of the 313 patients recruited, 13 were lost to follow up (left against medical advice), resulting in a final study population of 300 patients [Figure 1].

Figure 1. Recruitment of study population

Baseline demographics, clinical risk stratification, and unit of admission are summarized in Table 2. The mean age of the study population was 43.8 ± 19.1 years, and 169 patients (56.3%) were male. The mean boarding time was 12.25 ± 6.9 h. A total of 252 patients (84%) survived to hospital discharge.

Table 2. Patient demographic characteristics, boarding time, and clinical stratification according to National Early Warning Score 2 score (n=300)

The mean boarding time was higher in patients who died, as compared to those who were alive, but the difference was not found to be statistically significant (14.13 h vs. 11.89 h, P = 0.053). In hospital mortality increased significantly across risk categories, from low risk patients (6%) to high risk patients (28.3%) (P < 0.001). Patients admitted to the HDU had significantly higher in hospital mortality than those admitted to the ICU or wards (29.5% vs. 5.1% vs. 17.2%, respectively; P < 0.001). A detailed comparison is depicted in Table 3.

Table 3. Comparison of qualitative and quantitative markers with mortality

A ROC curve was plotted to assess the predictive ability of boarding time for in hospital mortality [Figure 2]. The Area under the ROC (AUROC) curve was 0.59 (95% confidence ınterval [CI]: 0.51–0.67; P = 0.046). A boarding time cut off of more than 9.98 h had a specificity of 70.8% and a sensitivity of 43.6% for predicting in hospital mortality.

Figure 2. The receiver operating characteristics curve depicting the association between emergency department boarding time and in‑hospital mortality

LR analysis showed that an increase in ED boarding time by 1 h was associated statistically significantly, but weakly, with an increased risk of in hospital mortality (adjusted odds ratio [aOR]: 1.06; 95% CI: 1.00– 1.12; P = 0.03). Admission to HDU/ICU and a NEWS2 score >4 (medium/high risk) were also identified as independent predictors of in hospital mortality. Age and sex were not significantly associated with mortality. The results are summarized in Table 4.

Table 4. Multivariate logistic regression analysis for predictors of in-hospital mortality

On post hoc subgroup analysis, increased ED boarding time did not significantly affect in hospital mortality within the individual ward, HDU, or ICU populations [Table 5].

Table 5. Post-hoc subgroup regression analysis of emergency department boarding time vs mortality based on unit of admittance

Discussion

Overcrowding of the ED is a rising concern in healthcare facilities, not only in India but globally. This phenomenon adversely affects patient care, impairs ED functioning, and reduces satisfaction among both patients and healthcare providers. Boarding of patients due to the unavailability of appropriate inpatient beds exacerbates this problem.

Various metrics have been used to quantify the length of ED stay. The term “lead time” refers to the duration from patient arrival at the ED to their admission to the inpatient unit.[13] Singer et al. used a similar concept of “boarding time,”[14] which we adopted in this study. We opted for this metric as we believe “lead time” is more susceptible to variation due to institutional protocols, thus potentially affecting the external validity of findings.

In our study, the mean age of participants was 43.8 years, with 56.33% being male. This mean age is considerably lower than that reported in similar studies,[14] possibly attributable to the shortage of inpatient beds for the geriatric population (age >65 years) during the study period. Another consideration is the possibly shorter life expectancy of the population under study, making them more vulnerable as compared to high income nations.

We found a mean ED boarding time of 12.25 h for patients who required immediate attention as per our center’s triage protocol, consistent with findings from studies[13,14] conducted in the U.S. and Canada. However, ED boarding times vary significantly across countries and healthcare systems, influenced by resource availability and admission practices. This heterogeneity is reflected in studies which have described ED boarding times as short as 34 min in Canada.[15] It is however unanimous that boarding times are increasing in EDs around the world. The Royal College of Emergency Medicine reported that approximately 10.2% of all Type I attendances in the United Kingdom (UK) had to wait more than 12 h from decision to admit till admission. This was 4.8 times higher than the figure for 2022.[16] It is crucial to note here that there is a lack of reliable data regarding boarding times in India and other developing world nations. This again signifies that this problem has been less extensively studied in our settings. The issue is amplified even further by the incredible variation in healthcare systems and quality across the length and breadth of a country like India, making generalizations difficult. This signifies the importance of our effort in aspiring to make sense of this problem in India.

The predictive value of boarding time in assessing in hospital mortality in our study was modest at best. The AUROC of 0.59 indicates limited discriminatory power. Although longer boarding times were statistically associated with increased mortality (aOR: 1.06), boarding time alone lacked sufficient sensitivity and specificity (43.6% and 70.8%, respectively) to serve as a reliable standalone predictor for clinical decision making or triage.

The relation between boarding times and in hospital mortality has been demonstrated in multiple studies previously.[14,17] Different cut offs have been identified in literature to be discriminatory for increased patient mortality. While Jones et al. demonstrated an increase in mortality beyond 5 h of ED stay up to 12 h in a retrospective study in the UK,[18] Roussel et al. showed that overnight ED stay was associated with a higher mortality in elderly patients.[19] Singer et al. concluded that boarding times <2 h were associated with significantly lower in hospital mortality than those boarded for more than 12 h.[14] On the contrary, multiple studies have demonstrated that there is no quantifiable association between prolonged ED stays and in hospital mortality, either.[9,13,20] These variations across multiple studies could be attributed to differences in study populations, study methodologies, patient characteristics as well as institutional protocols. This signifies the difficulty in attempting to summarize the problem, indicating clearly that there is no “One size fits all” approach. Our study was prospective, included only patients categorized red (requiring highest priority) on arrival to the ED, incorporating a patient population with a wide variety of nontraumatic diagnoses. A systematic review concluded that while there was a tendency towards an association between ED boarding and in hospital mortality, there was no strong evidence to suggest that prolonged ED boarding increases in hospital mortality.[10] This result closely mirrors our study findings. Most studies included in the review were retrospective in design, a drawback we have aimed to address with our study design. It appears reasonable that while prolonged ED boarding alone may not significantly affect mortality, especially taking into consideration globally increasing quality of ED care, attempts to shorten boarding times may be important for vulnerable and critically ill patients.

We also evaluated the prognostic utility of the NEWS2, which updates the original NEWS2[21] by incorporating new onset confusion and an alternative SpO₂ scale for Type II respiratory failure.[22] Though NEWS2 has shown predictive utility in conditions such as sepsis[23] and COVID 19,[24] as well as in early triage settings,[25] its ability to predict in hospital mortality remains debated.[26,27] Our findings are in agreement with previous research suggesting that a NEWS2 score >4 is a strong indicator for ICU admission but less reliable for mortality prediction. A recent meta analysis by Wei et al. echoed this, highlighting NEWS2’s high accuracy in early mortality prediction in ED settings but reduced performance for in hospital mortality.[28] They suggested that serial monitoring might enhance its prognostic value, though this remains understudied for NEWS2. While this has been studied previously with respect to the original NEWS score in patients admitted to general medicine wards,[29] data with respect to NEWS2 score is lacking. With increasing acceptance of NEWS2 score in emergency settings, its utility as a prognostic tool should be studied further in order to facilitate triaging and prioritization of hospital resources. The implications of such research have elevated importance in resource constrained healthcare systems like India and other low–middle income countries.

In our post hoc analysis, ED boarding time was not significantly associated with mortality in the critically ill patient group (ICU/HDU) as compared to noncritically ill (ward). The available literature on this topic presents a mixed picture. Verma et al. demonstrated an increase in in hospital mortality for critically ill patients who had a duration of stay >8 h in the ED.[30] It has to be contextualized that our ED has resuscitation rooms with ICU facilities available for temporary holding of patients, thus providing them appropriate interventions even prior to admission, which probably explains our results in any admission subgroup (ICU, HDU, or ward). The limitations inherent to post hoc analyses too must be acknowledged when interpreting these results, rendering them subjective and exploratory at best.

Our results suggest that while clinical severity at presentation and admission requirements posttreatment in the ED significantly impact in hospital mortality in the patient population, prolonged boarding times may weakly affect the same, especially in high risk populations. It seems prudent to infer that attempts should be made to reduce ED boarding times, especially in sick patients, within the logistic and resource constraints of the healthcare setup. Further research is required to study the nuances of this association, keeping in mind other confounding factors like patient comorbidities, resource availability, and quality of ED care, which could potentially affect this relation.

Limitations

Our study had a few limitations to consider. We had an assumption sample size of 300 study participants. Though the chosen sample size was considered sufficient to explore the research question in an initial or pilot capacity, this does bring the possibility of a Type II error into question with consequent underpowering of the multivariate LR model. Another key limitation of our study was the absence of confounding factors such as comorbidities and quality of ED care from our LR model. The former was a forced exclusion due to the presence of several pieces of missing data, potentially diluting the results. The quality of ED care and its impact on mortality are extremely variable, depending on multiple factors like the diagnosis, resource availability, and need for definitive care, making it difficult to describe the same quantitatively. Further, changes in the NEWS2 score in the ED were not assessed in the study. This could have been a reflection of the ongoing ED treatment, and could possibly be a better predictor of mortality than single scoring at presentation. Patients who died in the ED after admission advice were excluded from the data analysis, potentially biasing mortality estimates. Subjective protocols regarding triage and patient disposition also affect the generalizability of our results.

Conclusion

Prolonged ED boarding times may be weakly associated with in hospital mortality. Attempts should be made to identify and mitigate causes of ED boarding, especially among patients with higher severity of illness (NEWS2 score >4) at presentation.

How to cite this article: Thevrekandy V, Sreekumar A, Aggarwal P, Nayer J, Sanith KR. Emergency department boarding time and in‑hospital mortality: A prospective observational study. Turk J Emerg Med 2025;25:297-304.

The study was conducted after obtaining ethical approval from the ınstitute ethics committee (IECGP‑551/September 23, 2021), All India Institute of Medical Sciences, New Delhi.

A written informed consent has been obtained from all the participants.

• VT: Conceptualization, Data curation, Investigation, Methodology, Project administration, Resources, Validation, Writing
• AS: Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Software, Validation, Visualization, Writing – review and editing
• PA: Conceptualization, Investigation, Methodology, Project administration, Supervision, Validation, Writing – review and editing
• JN: Project administration, Supervision, Validation, Writing – review and editing.
• SKR: Data curation, Investigation.

None Declared.

None.

References

1. Mason S, Knowles E, Boyle A. Exit block in emergency departments: Arapid evidence review. Emerg Med J 2017;34:46-51.
2. Sreekala P, Dan A, Varghese EM. Patient waiting time in emergency department. Int J Sci Res Publ 2015;5:1.
3. Chen LC, Lin CC, Han CY, Hsieh CL, Wu CJ, Liang HF. An ınterpretative study on nurses’ perspectives of working in an overcrowded emergency department in Taiwan. Asian Nurs Res (Korean Soc Nurs Sci) 2018;12:62-8.
4. Goldhill DR, McNarry AF, Hadjianastassiou VG, Tekkis PP. The longer patients are in hospital before ıntensive care admission the higher their mortality. Intensive Care Med 2004;30:1908-13.
5. Sprivulis PC, Da Silva JA, Jacobs IG, Frazer AR, Jelinek GA. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust 2006;184:208-12.
6. Schull MJ, Vermeulen M, Slaughter G, Morrison L, Daly P. Emergency department crowding and thrombolysis delays in acute myocardial infarction. Ann Emerg Med 2004;44:577-85.
7. Pines JM, Pollack CV Jr., Diercks DB, Chang AM, Shofer FS, Hollander JE. The association between emergency department crowding and adverse cardiovascular outcomes in patients with chest pain. Acad Emerg Med 2009;16:617-25.
8. Pines JM, Localio AR, Hollander JE, Baxt WG, Lee H, Phillips C, et al. The impact of emergency department crowding measures on time to antibiotics for patients with community-acquired pneumonia. Ann Emerg Med 2007;50:510-6.
9. Al-Khathaami AM, Abulaban AA, Mohamed GE, Alamry AM, Kojan SM, Aljumah MA. The impact of `admit no bed` and long boarding times in the emergency department on stroke outcome. Saudi Med J 2014;35:993-8.
10. Boudi Z, Lauque D, Alsabri M, Östlundh L, Oneyji C, Khalemsky A, et al. Association between boarding in the emergency department and in-hospital mortality: A systematic review. PLoS One 2020;15:e0231253.
11. Sahu AK, Bhoi S, Galwankar S, Aggarwal P, Murmu L, Nayer J, et al. All India ınstitute of medical sciences triage protocol (ATP): ATP of a busy emergency department. J Emerg Trauma Shock 2020;13:107-9.
12. Welch J, Dean J, Hartin J. Using NEWS2: An essential component of reliable clinical assessment. Clin Med (Lond) 2022;22:509-13.
13. Junhasavasdikul D, Theerawit P, Kiatboonsri S. Association between admission delay and adverse outcome of emergency medical patients. Emerg Med J 2013;30:320-3.
14. Singer AJ, Thode HC Jr., Viccellio P, Pines JM. The association between length of emergency department boarding and mortality. Acad Emerg Med 2011;18:1324-9.
15. Montgomery P, Godfrey M, Mossey S, Conlon M, Bailey P. Emergency department boarding times for patients admitted to intensive care unit: Patient and organizational influences. Int Emerg Nurs 2014;22:105-11.
16. Draper S. Data Show 1.65 Million Patients in England Faced 12Hour Waits from Time of Arrival in A and Es in 2022 – RCEM. RCEM; 2024. Available from: https://rcem.ac.uk/data-show-165-million-patients-in-england-faced-12-hour-waits-from-timeof-arrival-in-aes-in-2022. [Last accessed on 2023 Feb 28].
17. Al-Qahtani S, Alsultan A, Haddad S, Alsaawi A, Alshehri M, Alsolamy S, et al. The association of duration of boarding in the emergency room and the outcome of patients admitted to the intensive care unit. BMC Emerg Med 2017;17:34.
18. Jones S, Moulton C, Swift S, Molyneux P, Black S, Mason N, et al. Association between delays to patient admission from the emergency department and all-cause 30-day mortality. Emerg Med J 2022;39:168-73.
19. Roussel M, Teissandier D, Yordanov Y, Balen F, Noizet M, Tazarourte K, et al. Overnight stay in the emergency department and mortality in older patients. JAMA Intern Med 2023;183:1378-85.
20. Agustin M, Price LL, Andoh-Duku A, LaCamera P. Impact of delayed admission to the ıntensive care unit from the emergency department upon sepsis outcomes and sepsis protocol compliance. Crit Care Res Pract 2017;2017:9616545.
21. Royal College of Physicians. National Early Warning Score 2 (NEWS2): Standardising the Assessment of Acute-İllness Severity in the NHS. RCP; 2017. Available from: https://www. rcplondon.ac.uk/projects/outputs/national-early-warningscore-news-2. [Last accessed on 2017 Dec 19].
22. Williams B. The National Early Warning Score 2 (NEWS2) in patients with hypercapnic respiratory failure. Clin Med (Lond) 2019;19:94-5.
23. Hsieh MS, Chiu KC, Chattopadhyay A, Lu TP, Liao SH, Chang CM, et al. Utilizing the National Early Warning Score 2 (NEWS2) to confirm the impact of emergency department management in sepsis patients: A cohort study from Taiwan 1998-2020. Int J Emerg Med 2024;17:42.
24. Myrstad M, Ihle-Hansen H, Tveita AA, Andersen EL, Nygård S, Tveit A, et al. National Early Warning Score 2 (NEWS2) on admission predicts severe disease and in-hospital mortality from COVİD-19 – A prospective cohort study. Scand J Trauma Resusc Emerg Med 2020;28:66.
25. Vergara P, Forero D, Bastidas A, Garcia JC, Blanco J, Azocar J, et al. Validation of the National Early Warning Score (NEWS)-2 for adults in the emergency department in a tertiary-level clinic in Colombia: Cohort study. Medicine (Baltimore) 2021;100:e27325.
26. Martín-Rodríguez F, López-IzquierdoR, Del Pozo VegasC, Delgado Benito JF, Carbajosa Rodríguez V, Diego RasillaMN, et al. Accuracy of National Early Warning Score 2 (NEWS2) in prehospital triage on ın-hospital early mortality: Amulti-center observational prospective cohort study. Prehosp Disaster Med 2019;34:610-8.
27. Engebretsen S, Bogstrand ST, Jacobsen D, Vitelli V, Rimstad R. NEWS2 versus a single-parameter system to identify critically ill medical patients in the emergency department. Resusc Plus 2020;3:100020.
28. Wei S, Xiong D, Wang J, Liang X, Wang J, Chen Y. The accuracy of the National Early Warning Score 2 in predicting early death in prehospital and emergency department settings: A systematic review and meta-analysis. Ann Transl Med 2023;11:95.
29. Loisa E, Kallonen A, Hoppu S, Tirkkonen J. Trends in the national early warning score are associated with subsequent mortality – A prospective three-centre observational study with 11,331 general ward patients. Resusc Plus 2022;10:100251.
30. Verma A, Shishodia S, Jaiswal S, Sheikh WR, Haldar M, Vishen A, et al. Increased length of stay of critically ıll patients in the emergency department associated with higher ın-hospital mortality. Indian J Crit Care Med 2021;25:1221-5.