Health policy and clinical practice/review articleSystematic Review of Emergency Department Crowding: Causes, Effects, and Solutions
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
References (115)
- et al.
A conceptual model of emergency department crowding
Ann Emerg Med
(2003) - et al.
Patients' perspective on choosing the emergency department for nonurgent medical care: a qualitative study exploring one reason for overcrowding
J Emerg Nurs
(2005) - et al.
Community influenza outbreaks and emergency department ambulance diversion
Ann Emerg Med
(2004) - et al.
Lack of integration, and seasonal variations in demand explained performance problems and waiting times for patients at emergency departments: a 3 years evaluation of the shift of responsibility between primary and secondary care by closure of two acute hospitals
Health Policy
(2001) - et al.
Waiting times in California's emergency departments
Ann Emerg Med
(2003) - et al.
Emergency department crowding: a point in time
Ann Emerg Med
(2003) - et al.
Emergency department contributors to ambulance diversion: a quantitative analysis
Ann Emerg Med
(2003) - et al.
Trends in the use and capacity of California's emergency departments, 1990-1999
Ann Emerg Med
(2002) - et al.
Factors affecting ED length-of-stay in surgical critical care patients
Am J Emerg Med
(1995) - et al.
Emergency departments and crowding in United States teaching hospitals
Ann Emerg Med
(1991)
The relationship between hospital capacity characteristics and emergency department volumes in Korea
Health Policy
Effects of hospital closures and hospital characteristics on emergency department ambulance diversion, Los Angeles County, 1998 to 2004
Ann Emerg Med
Delays in implementing admission orders for critical care patients associated with length of stay in emergency departments in six mid-Atlantic states
J Emerg Nurs
No place to unload: a preliminary analysis of the prevalence, risk factors, and consequences of ambulance diversion
Ann Emerg Med
Emergency department crowding and thrombolysis delays in acute myocardial infarction
Ann Emerg Med
Analysis of ambulance transports and diversions among US emergency departments
Ann Emerg Med
A 5-year time study analysis of emergency department patient care efficiency
Ann Emerg Med
Relationship between the National ED Overcrowding Scale and the number of patients who leave without being seen in an academic ED
Am J Emerg Med
The financial burden of emergency department congestion and hospital crowding for chest pain patients awaiting admission
Ann Emerg Med
Increased health care costs associated with ED overcrowding
Am J Emerg Med
The effect of emergency department crowding on paramedic ambulance availability
Ann Emerg Med
VESAS: a solution to seasonal fluctuations in emergency department census
Ann Emerg Med
Maximizing use of the emergency department observation unit: a novel hybrid design
Ann Emerg Med
Effect of increased ICU capacity on emergency department length of stay and ambulance diversion
Ann Emerg Med
Triage of patients out of the emergency department: three-year experience
Am J Emerg Med
Nonemergent ED patients referred to community resources after medical screening examination: characteristics, medical condition after 72 hours, and use of follow-up services
J Emerg Nurs
Utilization and impact of ambulance diversion at the community level
Prehosp Emerg Care
Approach to decreasing emergency department ambulance diversion hours
J Emerg Med
Ambulance diversion reduction: the Sacramento solution
Am J Emerg Med
Community trial to decrease ambulance diversion hours: the San Diego county patient destination trial
Ann Emerg Med
Hospital Emergency Departments: Crowded Conditions Vary Among Hospitals and Communities
Hospital-Based Emergency Care: At the Breaking Point
Do you want to die?The crisis in emergency care is taking its toll on doctors, nurses, and patients
Time
Hospitals get orders to reduce crowding in emergency rooms
New York Times
Emergency crews worry as hospitals say, “No vacancy.”
New York Times
State of emergency
Washington Post
Who's crowding emergency rooms?Right now it's managed-care patients
Wall Street Journal
Tying a knot in the unraveling health care safety net
Acad Emerg Med
Overcrowding crisis in our nation's emergency departments: is our safety net unraveling?
Pediatrics
Crisis in the emergency department
N Engl J Med
Care in the emergency department: how crowded is overcrowded?
Acad Emerg Med
The effects of ambulance diversion: a comprehensive review
Acad Emerg Med
Crowding
Ann Emerg Med
Clinical Epidemiology: A Basic Science for Clinical Medicine
Does this dyspneic patient in the emergency department have congestive heart failure?
JAMA
The measurement of observer agreement for categorical data
Biometrics
Primary care and public emergency department overcrowding
Am J Public Health
Nonurgent emergency department patient characteristics and barriers to primary care
Acad Emerg Med
Ambulance diversion is not associated with low acuity patients attending Perth metropolitan emergency departments
Emerg Med Australas
Cited by (0)
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.