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      Emergency department and hospital crowding: causes, consequences, and cures

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          Abstract

          Overcrowding with associated delays in patient care is a problem faced by emergency departments (EDs) worldwide. ED overcrowding can be the result of poor ED department design and prolonged throughput due to staffing, ancillary service performance, and flow processes. As such, the problem may be addressed by process improvements within the ED. A broad body of literature demonstrates that ED overcrowding can be a function of hospital capacity rather than an ED specific issue. Lack of institutional capacity leads to boarding in the ED with resultant ED crowding. This is a problem not solvable by the ED and must be addressed as an institution-wide problem. This paper discusses the causes of ED overcrowding, provides a brief overview of the drastic consequences, and discusses possible cures that have been successfully implemented.

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          The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments.

          Amanda R L Frazer, P Sprivulis, Heidi Jacobs … (2006)
          To examine the relationship between hospital and emergency department (ED) occupancy, as indicators of hospital overcrowding, and mortality after emergency admission. Retrospective analysis of 62 495 probabilistically linked emergency hospital admissions and death records. Three tertiary metropolitan hospitals between July 2000 and June 2003. All patients 18 years or older whose first ED attendance resulted in hospital admission during the study period. Deaths on days 2, 7 and 30 were evaluated against an Overcrowding Hazard Scale based on hospital and ED occupancy, after adjusting for age, diagnosis, referral source, urgency and mode of transport to hospital. There was a linear relationship between the Overcrowding Hazard Scale and deaths on Day 7 (r=0.98; 95% CI, 0.79-1.00). An Overcrowding Hazard Scale>2 was associated with an increased Day 2, Day 7 and Day 30 hazard ratio for death of 1.3 (95% CI, 1.1-1.6), 1.3 (95% CI, 1.2-1.5) and 1.2 (95% CI, 1.1-1.3), respectively. Deaths at 30 days associated with an Overcrowding Hazard Scale>2 compared with one of <3 were undifferentiated with respect to age, diagnosis, urgency, transport mode, referral source or hospital length of stay, but had longer ED durations of stay (risk ratio per hour of ED stay, 1.1; 95% CI, 1.1-1.1; P<0.001) and longer physician waiting times (risk ratio per hour of ED wait, 1.2; 95% CI, 1.1-1.3; P=0.01). Hospital and ED overcrowding is associated with increased mortality. The Overcrowding Hazard Scale may be used to assess the hazard associated with hospital and ED overcrowding. Reducing overcrowding may improve outcomes for patients requiring emergency hospital admission.
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            Emergency department crowding is associated with poor care for patients with severe pain.

            Jesse M. Pines, Judd E Hollander (2008)
            We study the impact of emergency department (ED) crowding on delays in treatment and nontreatment for patients with severe pain. We performed a retrospective cohort study of all patients presenting with severe pain to an inner-city, teaching ED during 17 months. Poor care was defined by 3 outcomes: not receiving treatment with pain medication while in the ED, a delay (>1 hour) from triage to first pain medication, and a delay (>1 hour) from room placement to first pain medication. Three validated crowding measures were assigned to each patient at triage. Logistic regression was used to test the association between crowding and outcomes. In 13,758 patients with severe pain, the mean age was 39 years (SD 16 years), 73% were black, and 64% were female patients. Half (49%) of the patients received pain medication. Of those treated, 3,965 (59%) experienced delays in treatment from triage and 1,319 (20%) experienced delays from time of room placement. After controlling for factors associated with the ED treatment of pain (race, sex, severity, and older age), nontreatment was independently associated with waiting room number (odds ratio [OR] 1.03 for each additional waiting patient; 95% confidence interval [CI] 1.02 to 1.03) and occupancy rate (OR 1.01 for each 10% increase in occupancy; 95% CI 0.99 to 1.04). Increasing waiting room number and occupancy rate also independently predicted delays in pain medication from triage (OR 1.05 for each waiting patient, 95% CI 1.04 to 1.06; OR 1.18 for each 10% increase in occupancy; 95% CI 1.15 to 1.21) and delay in pain medication from room placement (OR 1.02 for each waiting patient, 95% CI 1.01 to 1.03; OR 1.06 for each 10% increase in occupancy, 95% CI 1.04 to 1.08). ED crowding is associated with poor quality of care in patients with severe pain, with respect to total lack of treatment and delay until treatment.
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              ED patients: how nonurgent are they? Systematic review of the emergency medicine literature.

              Anne-Claire Durand, Stéphanie Gentile, Bénédicte Devictor … (2011)
              Nonurgent visits to emergency departments (ED) are a controversial issue; they have been negatively associated with crowding and costs. We have conducted a critical review of the literature regarding methods for categorizing ED visits into urgent or nonurgent and analyzed the proportions of nonurgent ED visits. We found 51 methods of categorization. Seventeen categorizations conducted prospectively in triage areas were based on somatic complaint and/or vital sign collection. Categorizations conducted retrospectively (n = 34) were based on the diagnosis, the results of tests obtained during the ED visit, and hospital admission. The proportions of nonurgent ED visits varied considerably: 4.8% to 90%, with a median of 32%. Comparisons of methods of categorization in the same population showed variability in levels of agreement. Our review has highlighted the lack of reliability and reproducibility. Copyright © 2011 Elsevier Inc. All rights reserved.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Clin Exp Emerg Med
                Journal ID (iso-abbrev): Clin Exp Emerg Med
                Journal ID (publisher-id): CEEM
                Title: Clinical and Experimental Emergency Medicine
                Publisher: The Korean Society of Emergency Medicine
                ISSN (Electronic): 2383-4625
                Publication date Collection: September 2019
                Publication date (Electronic): 12 July 2019
                Volume: 6
                Issue: 3
                Pages: 189-195
                Affiliations
                Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
                Author notes
                Correspondence to: Samita M Heslin Department of Emergency Medicine, Stony Brook University Hospital, 101 Nicolls Road, HSC Level 4-080, Stony Brook, NY 11794, USA E-mail: Samita.Heslin@ 123456StonyBrookMedicine.edu
                Author information
                http://orcid.org/0000-0002-7837-8834
                Article
                Publisher ID: ceem-18-022
                DOI: 10.15441/ceem.18.022
                PMC ID: 6774012
                PubMed ID: 31295991
                SO-VID: 2918d158-91da-4a1a-b9fb-6cc76a807e84
                Copyright © Copyright © 2019 The Korean Society of Emergency Medicine
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/).

                History
                Date received : 7 April 2018
                Date revision received : 29 June 2018
                Date accepted : 4 July 2018
                Categories
                Subject: Review Article

                Keywords: crowding,emergency service, hospital,patient safety
                Data availability:
                Keywords: crowding, emergency service, hospital, patient safety

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