Elsevier

Annals of Emergency Medicine

Volume 52, Issue 2, August 2008, Pages 126-136.e1
Annals of Emergency Medicine

Health policy and clinical practice/review article
Systematic Review of Emergency Department Crowding: Causes, Effects, and Solutions

https://doi.org/10.1016/j.annemergmed.2008.03.014Get rights and content

Emergency department (ED) crowding represents an international crisis that may affect the quality and access of health care. We conducted a comprehensive PubMed search to identify articles that (1) studied causes, effects, or solutions of ED crowding; (2) described data collection and analysis methodology; (3) occurred in a general ED setting; and (4) focused on everyday crowding. Two independent reviewers identified the relevant articles by consensus. We applied a 5-level quality assessment tool to grade the methodology of each study. From 4,271 abstracts and 188 full-text articles, the reviewers identified 93 articles meeting the inclusion criteria. A total of 33 articles studied causes, 27 articles studied effects, and 40 articles studied solutions of ED crowding. Commonly studied causes of crowding included nonurgent visits, “frequent-flyer” patients, influenza season, inadequate staffing, inpatient boarding, and hospital bed shortages. Commonly studied effects of crowding included patient mortality, transport delays, treatment delays, ambulance diversion, patient elopement, and financial effect. Commonly studied solutions of crowding included additional personnel, observation units, hospital bed access, nonurgent referrals, ambulance diversion, destination control, crowding measures, and queuing theory. The results illustrated the complex, multifaceted characteristics of the ED crowding problem. Additional high-quality studies may provide valuable contributions toward better understanding and alleviating the daily crisis. This structured overview of the literature may help to identify future directions for the crowding research agenda.

Introduction

The international crisis of emergency department (ED) crowding has received considerable attention, both in political1, 2 and lay3, 4, 5, 6, 7 venues. In 1986 the Emergency Medical Treatment and Labor Act mandated that all patients who present to an ED in the United States must receive a medical screening examination, regardless of their ability to pay.8 The unique role of the ED has prompted some to call it the safety net of the health care system.9, 10 Unfortunately, the increasing problem of crowding has strained this safety net to the “breaking point,” according to a recent report by the Institute of Medicine.2, 11

Escalation of the ED crowding problem has prompted researchers to investigate a number of scientific questions, some of which have been summarized by systematic literature reviews. One review characterized the diverse ways in which researchers have defined “overcrowding.”12 The authors found that the term has been frequently defined with various factors inside and outside of the ED and hospital. They concluded that the crowding research agenda would benefit from a consistent definition. Another review characterized ambulance diversion, whereby an ED advises ambulances to transport patients to other nearby hospitals when possible.13 The authors found that ambulance diversion is a frequent reaction to ED crowding, which may carry consequences including delayed patient transport and lost hospital revenue.

As noted by the Institute of Medicine, understanding the causes, effects, and solutions of the ED crowding problem is important.2 However, to the best of our knowledge, no previous systematic literature review has summarized this research. The objective of this review was to describe the scientific literature on ED crowding from the perspective of causes, effects, and solutions.

Section snippets

Search Strategy

We adopted the definition of the word “crowding” proposed by the American College of Emergency Physicians14: “Crowding occurs when the identified need for emergency services exceeds available resources for patient care in the emergency department, hospital, or both.” From this definition, we interpreted crowding to be a phenomenon that involves the interaction of supply and demand. We defined the scope of this review to include articles that met 4 criteria: (1) they studied causes, effects, or

Results

The MEDLINE query returned 4,271 abstracts. The reviewers identified 188 abstracts for full-text retrieval, of which 93 articles satisfied the criteria for inclusion in the review. A flow diagram of the selection process is presented in the Figure 1. The rate of reviewer agreement during the abstract screening phase, before consensus discussion, was 93% overall, 76% among included articles, and 94% among excluded articles. The κ statistic for chance-corrected agreement between the 2 reviewers

Limitations

This study has a number of limitations that merit discussion. First, we may not have captured every article that studied causes, effects, and solutions of ED crowding. We limited the search to English-language articles, so any relevant articles published in foreign languages were not included. We avoided searching the grey literature with a general purpose internet query, and we did not hand-search the references of included articles. If used, these 2 techniques might have impaired the

Discussion

A substantial body of literature exists describing the causes, effects, and solutions of ED crowding. The major themes among the causes of crowding included nonurgent visits, frequent-flyer patients, influenza season, inadequate staffing, inpatient boarding, and hospital bed shortages. The major themes among the effects of crowding included patient mortality, transport delays, treatment delays, ambulance diversion, patient elopement, and financial effect. The major themes among the solutions of

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    Supervising editor: David J. Magid, MD, MPH

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Dr. Hoot was supported by National Library of Medicine grant LM07450-02 and National Institute of General Medical Studies grant T32 GM07347. The research was also supported by National Library of Medicine grant R21 LM009002-01. The authors declare no conflicts of interest pertaining to the publication of this work.

    Publication dates: Available online April 23, 2008.

    Earn CME Credit: Continuing Medical Education for this article is available at: www.ACEP-EMedHome.com.

    Reprints not available from the authors.

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