Emergency Department Crowding Research Articles

Are there differences in low-acuity emergency department visits between culturally and linguistically diverse migrants and people with English-speaking background: a population-based linkage study of adults over 45

BackgroundGrowing numbers of avoidable low-acuity visits to emergency departments (ED) are a major health policy concern globally and are thought to contribute to ED crowding. This study explores the differences...

The Need for a New Approach to MCI Readiness in the Era of Emergency Department and Hospital Crowding.

Emergency department (ED) visit volumes have increased since 2007, with crowding in the United States reaching its highest levels in 2022. During this same period, mass casualty incidents (MCIs) have increased dramatically, both in frequency and severity, across the United States. Resuscitation of trauma patients is a time-sensitive process that requires immediate patient assessment by coordinated clinical teams in order to successfully diagnose and manage life-threatening injuries. To make resuscitation spaces immediately available for incoming patients, typical MCI plans call for rapidly relocating ED patients from their rooms into hallways or transferring them to open inpatient areas. With current levels of crowding, however, such alternate care spaces are often already in use and traditional MCI plans are increasingly unrealistic. With ED crowding worsening and the frequency of MCIs rising, there is a worrisome risk that EDs could fail in their efforts to save patients due to insufficient resources and spaces to meet the demands of critically injured patients. Hospitals must use innovative, novel response strategies to ensure sufficient patient care spaces in a short timeframe to save the most lives possible. In this commentary, we describe the use of buffer zones to help EDs mobilize an effective response to MCIs in the current context of severe hospital crowding.

Exploring Inpatient Unit Nurses’ Experience with Emergency Department Crowding, Access and Flow, and Associated Patient Outcomes

Background: Emergency department crowding and hospital access and flow are complex and long standing issues that negatively impact healthcare delivery. This study aims to address these issues through the perspectives of inpatient unit nurses. Strategies to alleviate ED crowding are supported by research exploring ED staff perspectives; however, a paucity of research exists addressing the perceptions of inpatient unit nurses and other key stakeholders. Methods: The research aims were addressed using qualitative method. Semi-structured virtual interviews were completed with eleven inpatient unit registered nurses from two hospital sites. A 17-question interview tool facilitated the collection of data. Results: Three main themes emerged from the data analysis. Inpatient unit nurses identified ED crowding, hospital access and flow, and site congestion as key areas of concern. In addition, the influence of understaffing was viewed as a contributor to ED crowding, resulting in negative outcomes for patient care. Conclusion: This study is the initial step to understanding different experiences, perceptions and knowledge on emergency department crowding and access and flow processes. Further research exploring diverse viewpoints on this topic is necessary given the interconnected organizational structure of healthcare today and how key stakeholders, outside of the emergency department, strongly influence access block and ED outflow.

Measuring the crowding of emergency departments: an assessment of the NEDOCS in Lombardy, Italy, and the development of a new objective indicator based on the waiting time for the first clinical assessment

BackgroundThere is no ubiquitous definition of Emergency Department (ED) crowding and several indicators have been proposed to measure it. The National ED Overcrowding Study (NEDOCS) score is among the most popular, even though it has been severely criticised. We used the waiting time for the physician’s initial assessment to evaluate the performance of the NEDOCS and proposed a new crowding indicator based on this objective measure.MethodsTo evaluate the NEDOCS, we used the 2022 data of all the Lombardy EDs and compared the distribution of waiting times across the five levels of the NEDOCS at ED arrival. To construct the new indicator, we estimated the centre-specific relationship between the total number of ED patients and the waiting time of those with minor or deferrable urgency. We defined seven classes of waiting times and calculated how many patients corresponded to an average waiting time in the classes. These centre-specific cutoffs were used to define the 7-level crowding indicator. The indicator was then compared to the NEDOCS score and validated on the first six months of 2023 data.ResultsPatients’ waiting time did not increase at the increase of the NEDOCS score, suggesting the absence of a relationship between this score and the effect of ED crowding on the ED capacity of evaluating new patients. The indicator we propose is easy to estimate in real-time and based on centre-specific cutoffs, which depend on the volume of yearly accesses. We observed minimal agreement between the proposed indicator and the NEDOCS in most EDs, both in the development and validation datasets.ConclusionsWe proposed to quantify ED crowding using the waiting time for physician’s initial assessment of patients with minor or deferrable urgency, which increases in crowding situations due to the prioritization of urgent patients. The centre-specific cutoffs avoid the problem of the heterogeneity of the volume of accesses and organization among EDs, while enabling a fair comparison between centres.

A Global Review of Advanced Practice Nursing in the Emergency Department.

As demands in the way of healthcare delivery increase, nurse practitioners have become essential components in optimizing access to healthcare and improving outcomes around the globe. The authors recognize the vital role nurse practitioners play globally and that education, practice, and credentialing differ significantly across countries. Many countries have a wide variation in educational requirements, resulting in a lack of adequate advanced practice nursing training and regulation of practice. Additionally, many countries are experiencing increased demands in the form of emergency services, with long waiting times and severe crowding in emergency departments. Worldwide, many programs are being developed to educate advanced practice nurses on improving emergency medical care, but developing such programs is a complex process This article aims to discuss the scope of practice and roles of advanced practice nurses globally. We will also attempt to clarify and improve these global standards and discuss competencies in this role.

162 Is There an Association Between Emergency Department Crowding and Emergency Medical Services Redirection?

162 Is There an Association Between Emergency Department Crowding and Emergency Medical Services Redirection?

440 Impact of Emergency Department Crowding on the Occurrence of In-Hospital Cardiac Arrest: A Propensity Score Matched Study

440 Impact of Emergency Department Crowding on the Occurrence of In-Hospital Cardiac Arrest: A Propensity Score Matched Study

Exploring the effects of emergency department crowding on emergency nurses.

Although the phenomenon of crowding in emergency departments (EDs) is not new, it remains a significant problem for patients, ED staff and the wider healthcare system. Crowding in EDs, which is also called overcrowding, has been widely explored in the literature, but there are relatively few studies of the subject from an emergency nurse perspective. This article reports the findings of a literature review that aimed to explore the effects of crowding on nurses working in EDs. Four key themes were identified from a synthesis of 16 articles included in the review: staffing and skill mix; inadequate care and the effect on nurses' well-being and stress levels; violence in the ED; and hospital metrics and patient flow. Further research is required to explore in more depth the effects of ED crowding on emergency nurses and to address the multiple factors that perpetuate the phenomenon.

The Effect of a Separate Flow of Patients With Small Traumatic Injuries on Consult Time and Patient Satisfaction: A Retrospective Cohort Study During COVID-19 in the Emergency Department.

With emergency department (ED) crowding and high workloads burdening healthcare, efficient patient flow management becomes increasingly crucial. A significant portion of this crowding is attributed to patients with minor traumatic injuries. The objective of this study is to investigate to what extent a separate patient flow for patients with small traumatic injuries influences consult times and patient satisfaction. During COVID-19, patients with small traumatic injuries in the ED were redirected to an outpatient clinic (the Fracture Clinic). The Fracture Clinic was maintained for seven weeks during which the consult time and patient satisfaction were recorded for every individual. Retrospectively, the same procedure was followed for the seven weeks prior to the outbreak of COVID, with the regular procedure in place. In total, 922 patients were included in the research: 415 patients in the intervention group (Fracture Clinic) and 507 patients in the control group (ED group). The consult time in the Fracture Clinic (median = 30 min) is significantly lower compared to the ED group (median = 86 min) (U = 25,147.500, z = 19.9, p < 0.001). The overall consult in terms of patient satisfaction scored higher for the Fracture Clinic Group than the ED group (T[df] = -4.449 [479], p < 0.001). The Fracture Clinic resulted in shorter consult times and an increased patient satisfaction compared to the usual patient flow for patients with small traumatic injuries in the ED. These patients could be redirected to an outpatient clinical setting to improve efficiency in patient flow, while avoiding a negative impact from the triage system in which they usually are the lowest priority.

Emergency department visits as a potential opportunity to promote primary care attachment and modify utilization patterns – results of a pilot study in Berlin, Germany

BackgroundUtilization by low acuity patients contributes to emergency department (ED) crowding. Both knowledge deficits about adequate care levels and access barriers in primary care are important promoters of such presentations. Concurrently, not having a general practitioner (GP) increases the likelihood of low-acuity ED utilization. This pilot study thus investigated feasibility, acceptance, and potential effects of an ED-delivered intervention for low-acuity patients with no regular primary care provider, consisting of an educational leaflet on acute care options and an optional GP appointment scheduling service.MethodsLow-acuity ED consulters not attached to a GP were given an information leaflet about alternative care offers for acute health problems and offered optional personal appointment scheduling at a local GP practice. Patients were surveyed on demographics, medical characteristics, health care utilization, valuation of the intervention, and reasons for not being attached to a GP and visiting the ED. A follow-up survey was conducted after twelve months. Trends in health and health care utilization were evaluated.ResultsBetween December 2020 and April 2022, n = 160 patients were enrolled, n = 114 were followed up. The study population was characterized by young age (mean 30.6 years) and predominantly good general health. Besides good health, personal mobility was a central reason for not being attached to a GP, but general preference for specialists and bad experiences with primary care were also mentioned. Most frequently stated motives for the ED consultation were subjective distress and anxiety, a belief in the superiority of the hospital, and access problems in primary care. The interventional offers were favorably valued, 52.5% (n = 84) accepted the GP appointment scheduling service offer. At follow-up, GP utilization had significantly increased, while there were no significant changes regarding utilization of other providers, including ED. An additional practice survey showed a 63.0% take-up rate for the appointment service.ConclusionsWith this pilot study, we were able to show that a personalized appointment scheduling service seems to be a promising approach to promote GP attachment and increase primary care utilization in patients without a regular GP in a highly urbanized setting. Further larger-scale studies are needed to investigate potential quantitative effects on ED visits.Trial RegistrationGerman Clinical Trials Register (DRKS00023480); date 2020/11/27.

Reduced Time to Admit Emergency Department Patients to Inpatient Beds Using Outflow Barrier Analysis and Process Improvement.

Because admitted emergency department (ED) patients waiting for an inpatient bed contribute to dangerous ED crowding, we conducted a patient flow investigation to discover and solve outflow delays. After solution implementation, we measured whether the time admitted ED patients waited to leave the ED was reduced. In June 2022, a team using Lean Healthcare methodologies identified flow delays and underlying barriers in a Midwest, mid-sized hospital. We calculated barriers' magnitudes of burden by the frequency of involvement in delays. During October-December 2022, solutions targeting barriers were implemented. In October 2023, we tested whether waiting time, defined as daily median time in minutes from admission disposition to departure (ADtoD), declined by conducting independent sample, single-tailed t-test comparing pre- to post-intervention time periods, January 1-September 30, 2022 (273 days) to January 1-September 30, 2023 (273 days). Additionally, we regressed ADtoD onto pre-/post period while controlling for ED volume (total daily admissions and ED daily encounters) and hospital occupancy. A run chart analysis of monthly median ADtoD assessed improvement sustainability. Process mapping revealed that three departments (ED, environmental services [EVS], and transport services) co-produced the outflow of admitted ED patients wherein 18 delays were identified. The EVS-clinical care collaboration failures explained 61% (11/18) of delays. Technology contributed to 78% (14/18) of delays primarily because staff's technology did not display needed information, a condition we coined "digital blindness." Comparing pre- and post-intervention days (3,144 patients admitted pre-intervention and 3,256 patients post), the median minutes a patient waited (ADtoD) significantly decreased (96.4 to 87.1 minutes, P = 0.04), even while daily ED encounter volume significantly increased (110.7 to 117.3 encounters per day, P < 0.001). After controlling in regression for other factors associated with waiting, the intervention reduced ADtoD by 12.7 minutes per patient (standard error 5.10, P = 0.01; 95% confidence interval -22.7, -2.7). We estimate that the intervention translated to ED staff avoiding 689 hours of admitted patient boarding over nine months (ADtoD coefficient [-12.7 minutes] multiplied by post-intervention ED admissions [3,256] and divided by 60). Run chart analysis substantiated the intervention's sustainability over nine months. After systemwide patient flow investigation, solutions resolving digital blindness and environmental services-clinical care collaboration failures significantly reduced ED admitted patient boarding.

Preventive Health Services Offered in a Sampling of US Emergency Departments, 2022-2023.

In the United States, more chronic and preventive healthcare is being delivered in the emergency department (ED) setting. Understanding the availability of preventive health services in the ED setting is crucial. Our goal was to understand the availability of a subset of preventive health services in US EDs and explore how that has changed over time. In 2022-2023, using the National Emergency Department Inventory (NEDI)-USA, we surveyed a random 20% (1,064) sampling of all 5,613 US EDs. We asked directors of these EDs about the availability of and preference for 12 preventive health services, social worker availability, self-reported percentage of uninsured ED patients, and measures of ED crowding. We also asked about perceptions of barriers to implementing preventive health services in the ED. We used unadjusted and multivariable logistic regression models to compare service frequency in 2022-2023 to prior findings from 2008-2009 that represented a 5.7% random sampling of all EDs. Among 302 responders to the 2022-2023 survey (5.4% random sampling, 28.4% response rate), 94% reported offering at least one preventive health service, with a median of five services. The most common service offered was intimate partner violence screening (83%), while the least common was routine HIV screening (19%). Seven services (eg, intimate partner violence, alcohol risk, and smoking cessation screening) had a higher odds of being offered in 2022-2023 than in 2008-2009; findings were unchanged in sensitivity analyses. A small proportion of directors opposed offering preventive health services. However, many expressed concerns that preventive health services in the ED would lead to longer lengths of stay (56%), increased costs to their ED (58%), a diversion of staff time from providing acute care (50%), or that their patients would not have access to adequate follow-up (49%). Nearly all EDs offer at least one preventive health service. Many offer multiple services; rates were higher than those identified in 2008-2009, in both unadjusted and multivariable models. Although limited by the response rate, this work provides the most recent and comprehensive snapshot of the type and frequency of a subset of preventive health services currently offered in US EDs.

Solving an Emergency Department Crowding Problem by Establishing an Intermediate Care Unit

Solving an Emergency Department Crowding Problem by Establishing an Intermediate Care Unit

Decreased patient discharges on weekends part 1: what do the data tell us?

We believe that hospital and emergency department (ED) crowding is exacerbated on Mondays because fewer in-patients are discharged on the weekend. In part 1 of 3 concurrent studies, we documented the number of weekend discharges and the extent of hospital and ED crowding on the days following weekends. We conducted a data analysis study at The Ottawa Hospital, a major academic health sciences center with two EDs. We created reports of the 18-month period (January 1, 2022-June 30, 2023) regarding the status of in-patients at the two campuses. We compared the total admissions, discharges, and hospital occupancy on weekends (or long weekends), the Monday following weekends (or Tuesday following long weekends), or Tuesdays-Fridays. For these three time periods, we also compared the proportion of ED beds occupied by admitted patients to all ED beds, as well as the proportion of days with > 70% admitted patients housed in the ED at 8:00am. Our data for 55,692 patients demonstrated that on weekends compared to weekdays, there were almost 50% fewer discharges with the ratio of admissions to discharges averaging 1.16 (95% CI 1.10-1.22). This was accompanied by a 2.4% absolute increase (P < 0.001) in hospital occupancy on Mondays or Tuesdays, often exceeding 100%. Both EDs are particularly crowded on these Mondays and Tuesdays with the proportion of admitted patients to regular ED beds averaging 68%. We observed serious crowding with > 70% occupancy with admitted patients on almost 50% of Mondays. We have demonstrated that there are much fewer discharges on weekends, and this is associated with significant hospital and ED crowding on Mondays. This blocks safe and timely access to beds for newly arriving patients in the ED. These results should spur Canadian hospitals to evaluate their own data and seek solutions to this important problem.

Decreased patient discharges on weekends: part 2-what do the ward nurses tell us?

Hospital and emergency department (ED) crowding is exacerbated on Mondays because fewer in-patients are discharged during the weekend. We evaluated the experiences and attitudes of in-patient ward nurses to better understand the challenges they face when considering the weekend discharge of their patients. We conducted a qualitative study of in-patient ward nurses, using the theoretical domains framework (TDF), at two campuses of a major academic health sciences centre. The interview guides consisted of, first, a series of questions to explore the typical processes involved for safe patient discharges and, second, exploration of the influence of the 14 TDF domains. All interviews were audio-recorded, transcribed verbatim, and anonymized and then imported into NVivo qualitative software for data management and analysis. Analysis was conducted in three stages (coding, generation of specific beliefs, identification of relevant and nonrelevant domains). The 28 interviewed nurses represented a variety of medical, surgical and other wards, and reported being acutely aware of the pressures to discharge patients on weekends (knowledge). They believed that increasing weekend discharges would improve hospital flow and aid in decanting the ED (beliefs about consequences). However, they also acknowledged that the weekend discharge pressures might result in patients being discharged prematurely and bouncing back to the hospital (beliefs about consequences). Overall, the nurses reported that as a hospital culture, discharging patients was not much of a priority (goals; environmental context and resources). We know there are much fewer discharges on weekends, and this is associated with significant hospital and ED crowding on Mondays. This study has illuminated the many challenges faced by in-patient ward nurses when considering the discharge of admitted patients on weekends. In order to decrease ED and hospital crowding related to decreased weekend discharges, hospitals will need to effect a culture change amongst all staff.

Interventions to improve emergency department throughput and care delivery indicators: A systematic review and meta-analysis.

Emergency department (ED) crowding has repercussions on acute care, contributing to prolonged wait times, length of stay, and left without being seen (LWBS). These indicators are regarded as systemic shortcomings, reflecting a failure to provide equitable and accessible acute care. The objective was to evaluate the effectiveness of interventions aimed at improving ED care delivery indicators. This was a systematic review and meta-analysis of randomized controlled trials (RCTs) assessing ED interventions aimed at reducing key metrics of time to provider (TTP), time to disposition (TTD), and LWBS. We excluded disease-specific trials (e.g., stroke). We used Cochrane's revised tool to assess the risk of bias and Grading of Recommendations, Assessment, Development, and Evaluations to rate the quality of evidence. The meta-analysis was performed using a random-effects model and Cochrane Q test for heterogeneity. Data were summarized as means (±SD) for continuous variables and risk ratios (RR) with 95% confidence intervals (CIs). We searched MEDLINE, EMBASE, and other major databases. A total of 1850 references were scanned and 20 RCTs were selected for inclusion. The trials reported at least one of the three outcomes of TTD, TTP, or LWBS. Most interventions focused on triage liaison physician and point-of-care (POC) testing. Others included upfront expedited workup (ordering tests before full evaluation by a provider), scribes, triage kiosks, and sending notifications to consultants or residents. POC testing decreased TTD by an average of 5-96 min (high heterogeneity) but slightly increased TTP by a mean difference of 2 min (95% CI 0.6-4 min). Utilizing a triage liaison physician reduced TTD by 28 min (95% CI 19-37 min; moderate-quality evidence) and was more effective in reducing LWBS than routine triage (RR 0.76, 95% CI 0.66-0.88; moderate quality). Operational strategies such as POC testing and triage liaison physicians could mitigate the impact of ED crowding and appear to be effective. The current evidence supports these strategies when tailored to the appropriate practice environment.

Decreased patient discharges on weekends part 3: what do the leaders tell us?

Emergency department (ED) crowding is a significant challenge to providing safe and quality care to patients. We know that hospital and ED crowding is exacerbated on Mondays because fewer in-patients are discharged on the weekend. We evaluated barriers and potential solutions to improve in-patient flow and diminished weekend discharges, in hopes of decreasing the severe ED crowding observed on Mondays. In this observational study, we conducted interviews of (a) leaders at The Ottawa Hospital, a major academic health sciences centre (nursing, allied health, physicians), and (b) leaders of community facilities (long-term care and chronic hospital) that receive patients from the hospital, and (c) home care. Each interview was conducted individually and addressed perceived barriers to the discharge of hospital in-patients on weekends as well as potential solutions. An inductive thematic analysis was conducted whereby themes were organized into a summary table of barriers and solutions. We interviewed 40 leaders including 30 nursing, physician, and allied health leaders from the hospital as well as 10 senior personnel from community facilities and home care. Many barriers to weekend discharges were identified, highlighting that this problem is complex with many interdependent internal and external factors. Fortunately, many specific potential solutions were suggested, in immediate, short-term and long-term time horizons. While many solutions require additional resources, others require a culture change whereby hospital and community stakeholders recognize that services must be provided consistently, seven days a week. We have identified the complex and interdependent barriers to weekend discharges of in-patients. There are numerous specific opportunities for hospital staff and services, physicians, and community facilities to provide the same patient care on weekends as on weekdays. This will lead to improved patient flow and safety, and to decreased ED crowding on Mondays.

Public Beliefs About Accessibility and Quality of Emergency Departments in Germany.

It is well established that emergency department (ED) crowding leads to worse health outcomes. Although various patient surveys provide information about reasons to visit EDs, less is known in terms of beliefs about EDs among the general population. This study examines public beliefs regarding accessibility and quality of EDs and their associations with social characteristics (gender, age, education, immigration background) as well as knowledge about emergency care services and health literacy. We conducted a cross-sectional study based on a random sample of 2,404 adults living in Hamburg, Germany, in winter 2021/2022. We developed eight statements regarding accessibility and quality of EDs leading to two scales (Cronbach's α accessibility = 0.76 and quality of care = 0.75). Descriptive statistics of the eight items are shown and linear regression were conducted to determine associations of the two scales with social characteristics as well as knowledge about emergency care services and health literacy (HLS-EU-Q6). Nearly 44% of the respondents agreed that "you can always go to an ED, if you do not get a short-term appointment with a general practitioner or specialist." And 38% agreed with the statement, "If you do not have the time during normal practice hours due to your work, you can always go to an ED." In terms of quality, 38% believed that doctors in EDs are more competent than doctors in general practice, and 25% believed that doctors in EDs are more competent than doctors in specialized practices. In the fully adjusted model, public beliefs about emergency care accessibility and quality of EDs were significantly associated with all social characteristics and knowledge of emergency care options with the strongest associations between knowledge and accessibility (β = -0.17; P < 0.001) and between education and quality (β = -0.23; P < 0.001). We found endorsement of public beliefs about accessibility and quality of EDs that can lead to inappropriate utilization. Our results also suggest that knowledge of different emergency services plays an important role. Therefore, after system-related reorganizations of emergency care, information campaigns about such services tailored to socially deprived populations may help alleviate the issue of crowding.

The skåne emergency medicine (SEM) cohort

BackgroundIn the European Union alone, more than 100 million people present to the emergency department (ED) each year, and this has increased steadily year-on-year by 2–3%. Better patient management decisions have the potential to reduce ED crowding, the number of diagnostic tests, the use of inpatient beds, and healthcare costs.MethodsWe have established the Skåne Emergency Medicine (SEM) cohort for developing clinical decision support systems (CDSS) based on artificial intelligence or machine learning as well as traditional statistical methods. The SEM cohort consists of 325 539 unselected unique patients with 630 275 visits from January 1st, 2017 to December 31st, 2018 at eight EDs in the region Skåne in southern Sweden. Data on sociodemographics, previous diseases and current medication are available for each ED patient visit, as well as their chief complaint, test results, disposition and the outcome in the form of subsequent diagnoses, treatments, healthcare costs and mortality within a follow-up period of at least 30 days, and up to 3 years.DiscussionThe SEM cohort provides a platform for CDSS research, and we welcome collaboration. In addition, SEM’s large amount of real-world patient data with almost complete short-term follow-up will allow research in epidemiology, patient management, diagnostics, prognostics, ED crowding, resource allocation, and social medicine.

Perceived Work Demands and Emergency Department Crowding as Predictors of Objective Stress Among Emergency Physicians: A Shift-Level Approach.

To understand shift-level determinants of emergency physician (EP) burnout, relationships were tested between EP shift demands, stress, and fatigue. EP ( n = 16) were assessed over 114 shifts that occurred before and during the COVID-19 pandemic. Salivary cortisol (an indicator of stress) and self-reported fatigue were collected prior to and following each shift. An objective crowding score (National Emergency Department Overcrowding Scale) per shift was calculated. Shift demands were assessed at the end of each shift. Multilevel models revealed that shift demands, National Emergency Department Overcrowding Scale, and the pandemic were related to higher levels of end-of-shift cortisol, but not fatigue. Cortisol levels were higher for shifts with a higher number of demands, greater crowding, and during the pandemic. Shift demands predicted objective indicators of stress, but not self-reported fatigue. Interventions are needed to decrease stress and shift demands to reduce EP burnout.