Andy H. Lee, MD, MBA; and Rohit B. Sangal, MD, MBA, on behalf of the SAEM ED Admin and Clinical Operations Committee.



Level-loading is a health system-wide approach to managing emergency department (ED) and inpatient capacity across multiple hospitals to minimize crowding and ED boarding. The goal of this strategy is to transfer patients from sites at high or maximum levels of occupancy to sites with lower occupancy without compromising the quality of care or legal obligations of EDs and hospitals.

The most common forms of level-loading in current practice occur prior to ED arrival, in the waiting room after triage, or after the need for inpatient admission has been determined. These practices should take into account local regulations, such as the Emergency Medical Treatment & Labor Act (EMTALA) in the United States which requires patient screening and stabilization once patients arrive in the ED. Strategies to level-load prior to triage often mirror queue management in theme parks, such as by publishing estimated wait times online, which may prompt patients to preferentially go to an ED with an anticipated shorter wait time.1 Some EDs also actively manage capacity by having command centers oversee ED-to-ED transfers or link directly with local emergency medical services (EMS) for destination control to a specific ED within the system.2 This approach is preferable to going on EMS diversion upon reaching maximum capacity.3 Some hospital systems level-load patients who require admission from the ED by transferring patients from the crowded ED to the inpatient ward of a network hospital that can manage the patient's medical needs.4,5 This helps alleviate prolonged ED boarding and crowding.

Level-loading improves capacity management by distributing patient volume across the combined capacity of multiple hospitals. This helps to avoid situations where there is overcrowding at one site and unused capacity at another, which can be especially common in integrated health systems with multiple academic and community sites. Implementation of level-loading strategies significantly improves ED and hospital operational metrics. A case study where two nearby EDs published wait times found a significant reduction in the fraction of wait times that were over 2 hours.1 ED’s that have active capacity management programs with EMS spend less time in diversion and have decreased EMS offload times.2,3 Tertiary hospitals that have implemented level-loading interfacility transfer programs have demonstrated reduced ED length of stay and were able to reduce inpatient bed days without safety events.4,5 This strategy was also successfully used in an 11-hospital New York City hospital network at the height of the COVID-19 pandemic to partially relieve overwhelming demand at the most impacted hospitals.6,7

Interested Parties

Level-loading programs inherently require consultation and collaboration with multiple interested party groups to ensure success. The involvement of health system leadership is necessary to align goals and resources across multiple hospitals. Displaying wait times requires IT resources to integrate real-time electronic health record (EHR) information with the public-facing display and alignment among regulatory, marketing, and frontline staff for consistent and effective messaging. Internal transfers within a healthcare system require collaboration between ED’s and admitting services, determination of inclusion criteria for transfers, and ongoing review to address barriers.4 This may also be adapted to fit within the framework of existing command centers. Strategies involving collaboration with EMS involve additional external interested parties and may require governmental agency approval and consultation with other local hospitals.2,3 It is also important for patient advocacy and quality and safety teams to be involved to monitor for safety events and health disparities.

Key Points

  • Level-loading is a strategy that addresses ED crowding and boarding by transferring patients from crowded hospitals with high occupancy to hospitals with lower occupancy or excess capacity.
  • Some examples of front-end interventions include publishing wait times for patients or EMS direction to EDs with capacity while back-end interventions involve inter-facility transportation of patients boarding in the ED to available inpatient wards.
  • Hospitals that have implemented level-loading programs have shown improvements in operational metrics including decreased ED length of stay, decreased wait times, and decreased time in EMS diversion.
  • Collaboration with both internal and external interested parties is necessary for successful implementation and ongoing monitoring for potential safety events and health disparities is recommended.



  1. Xie B, Youash S. The effects of publishing emergency department wait time on patient utilization patterns in a community with two emergency department sites: a retrospective, quasi-experiment design. Int J Emerg Med. 2011 Jun 14; 4(1):29.
  2. Felice J, Coughlin RF, Burns K, Chmura C, Bogucki S, Cone DC, Joseph D, Parwani V, Li F, Saxa T, Ulrich A. Effects of Real-time EMS Direction on Optimizing EMS Turnaround and Load-balancing Between Neighboring Hospital Campuses. Prehosp Emerg Care. 2019 Nov-Dec; 23(6):788-794.
  3. Sprivulis, P, Gerrard B. Internet-accessible emergency department workload information reduces ambulance diversion. Prehosp Emerg Care. 2005 Jul-Sep; 9(3):285-291.
  4. Lee AH, Berlyand Y, Dunn PF, Goralnick E, Le LH, Raja AS, Baugh JJ, Cooper S, Yun BJ. Level-loading a health system by transferring emergency department patients to a community hospital: prospective cohort study. Am J Emerg Med. 2022 Oct; 60:29-33.
  5. Ahn JY, Ryoo HW, Park J, Kim JK, Lee MJ, Kim KY, Shin SD, Cha WC, Seo JS, Kim YA. New Intervention Model of Regional Transfer Network System to Alleviate Crowding of Regional Emergency Medical Center. J Korean Med Sci. 2016 May; 31(5):806-813.
  6. Lee AH, Dunn PF, Cooper S, Seger R, Raja AS, Safavi KC, Yun BJ. COVID-19 Level-Loading: Transferring Emergency Department Patients to a Partner Academic Medical Center Within a Healthcare System. Am J Med Qual. 2021 Sep-Oct 01; 36(5):368-370.
  7. Boudourakis L, Silvestri DM, Natsui S, et al. Using interfacility transfers to 'level-load' demand from surging COVID-19 patients: lessons from NYC Health + Hospitals. Health Affairs Blog.