Eleven years ago, a 45-year-old aboriginal double-amputee named Brian Sinclair was found dead by ED staff in a Winnipeg, Manitoba, emergency department.1 He had been in the waiting room for 34 hours. A physician had sent him to the emergency department with a referral note later found in his pocket. The cause of death was septic shock secondary to a urinary tract infection.
This is an extreme example of the effect of ED overcrowding on our patients. Yet the literature is rife with stories. There are many known patient-centered consequences of ED overcrowding in addition to increased mortality, including delays in evaluation and essential care.2-9 Overcrowding is associated with more medical errors, increased lengths of stay, worse outcomes, and reduced patient satisfaction.10-13 ED overcrowding may contribute to negative consequences not only for patients but also for clinicians. Overcrowding has been shown to increase stress and exposure to violence for ED staff.5,14
Below, I outline some solutions to ED overcrowding with the hope that, collectively, we can help alleviate the problems of ED overcrowding and improve not only patient outcomes but our work-related stress.
Solutions Must Be Aimed at Hospital-wide Access Block
Many people incorrectly believe that overcrowding stems from high numbers of patients presenting with minor complaints.15,16 In fact, the bulk of ED overcrowding is caused by access block—the inability to transfer patients out of the emergency department to an inpatient bed once their ED treatment has been completed.
The most common bottleneck in the emergency department is the nurse-staffed stretcher, a bed for patients who aren’t able to sit or ambulate and need nurse monitoring. These are often occupied by admitted inpatients in the emergency department. On average, hospitals leave high-acuity patients in emergency department hallways for 46,000 hours per year, resulting in the kinds of deterioration in patient care outlined above. However, this is equivalent to only 1 to 2 percent of inpatient capacity or, on average, 1.5 hours of the total inpatient length of stay. In other words, if inpatient length of stay could be reduced by an average of 1.5 hours, ED hallway medicine and overcrowding would essentially vanish.17
A culture shift in the entire hospital and outpatient services (rather than just the emergency department) that recognizes the impact of hospital-wide efficiency on ED overcrowding is required. Incentives, performance measurements (such as consultant turnaround times), demand-capacity matching, and queue management contingencies for each hospital unit are required to improve hospital-wide efficiency and accountability for overcrowding.18 Each unit will have unique solutions that require innovative thinking and implementation.
But we should lead by example. Emergency departments should be exemplary for the rest of the hospital in practicing accountability for ED overcrowding. One example of a strategy to improve accountability and efficiency of consulting services as well as throughput in teaching hospitals is having a senior consultant resident briefly assess ED patients and make a disposition decision/admitting orders before junior learners serially assess the patient and review with their seniors.19 This may ruffle some academic feathers, so a middle ground would be to implement this strategy at times known to be busy or when ED capacity is approaching critical levels.
Overtesting and Overcare Contributes to ED Overcrowding
The more crowded it gets, the less time we spend with each patient. This may make it more likely that clinicians order more tests in an effort to make up for clinical assessments that are limited by time constraints. However, this testing leads to longer lengths of stay. Labs and radiology departments get backed up. While patients may say they have come to the emergency department for a test, a thorough history and physical with clear explanations is often as or more effective in satisfying the patient than rushing through an assessment and ordering unnecessary tests that take longer and may lead to iatrogenic harm. Emergency physicians who order more tests compared to their peers are less efficient; a lower number of patients are assessed and treated per shift without a difference in patient outcomes.20
Physician-specific solutions to overtesting have been described, such as a five-step systematic approach to curb unnecessary diagnostic test ordering:
- Decide what diagnosis is being investigated before ordering a test.
- Determine the pretest probability of the condition in question.
- Decide whether to rule the condition in or out.
- Decide what will be done if the test result is positive or negative.
- Ask whether ordering the test could harm the patient.21
It is important for emergency physicians to understand that patients do not have a disease but rather have a probability of a disease. Diagnostic tests are merely revisions of probabilities. The possible interpretations of a test should be considered before test ordering. If a test result leads to a revision in the probability of a disease, ask whether that will entail a change in subsequent management. If not, use of that test should be reconsidered.22
Take the time to complete a thorough clinical assessment and provide clear, compassionate communication. Consider further investigations or referral only if they clearly improve emergency management.
Consistently minimizing overcare can be simpler than you realize and can alleviate overcrowding. Order oral medications or fluids rather than IV ones whenever possible. Consider discharging (or admitting) patients rather than keeping them in the emergency department overnight just for convenience. Removing patients from cardiac monitors can reduce alarm fatigue. Use space and resources efficiently; get patients out of ED stretchers when they are no longer indicated.
“More” or “invasive” care is not necessarily better care. Choose every intervention only after a careful risk and benefit analysis. Complete reassessments in a timely manner, before assessing new patients. Given two patients with equal acuity, attend to the patient who is likely to be moved through the emergency department more efficiently so that the bed they are occupying can be freed up for another patient. Avoid delaying uncomfortable or difficult decisions. Delegate non-ED physician tasks to nurses, porters, consultants, and other members of the team. Spending 30 minutes on a tendon laceration repair when there is a plastic surgeon on call or the repair can be delayed while there are 30 patients waiting to be seen is not an efficient use of your time. It is important to keep patient flow and situational awareness in mind constantly during the ED shift, reviewing flow-sensitive decision points before assessing the next noncritical patient.
Developing a strong sense of your mandate as an emergency physician—to diagnose acute illness rather than screen for chronic diseases and to model professional behavior to your team and colleagues—can go a long way to setting the stage for the necessary culture in your hospital that values efficient, excellent care.
Anticipate and Address Variability to Manage ED Overcrowding
Disease outbreaks and mass casualty events as well as scheduled variability (eg, diminished consultant availability on weekends) can cause enormous variability in hospital bed demand. Some of this variability is highly predictable.23 The resultant surges in patient care needs can be managed by hiring a 24-hour ED flow director who is accountable for ED overcrowding, day-ahead demand-capacity matching throughout the hospital, twice-daily multi-unit bed meetings, accountable care unit strategies, and smooth scheduled variability planning.24 The individual physician must develop a “higher gear” as needed and model this for trainees and colleagues.
ED overcrowding should be understood by all health care professionals, administrators, and politicians to be a systemwide problem with accountability on every level, from individual emergency physicians to government officials. We should make every effort to help improve ED overcrowding. This applies both to our clinical practice and to taking on leadership roles that can affect change at the hospital and government levels. If we all adapt this mindset, I have confidence that the ED overcrowding problem will be solved.
Special thanks to Dr. Grant Innes, Dr. Howard Ovens, and Dr. Samuel Campbell for their expert contributions to the podcast that inspired this article.
ACEP has a variety of resources to help you address ED crowding and patient boarding at your hospital, including research papers, policy statements, and CME. Visit www.acep.org/administration/crowding–boarding to learn more.
- Gerster J. Brian Sinclair: a man was ignored to death in an ER 10 years ago. It could happen again. Global News. Sept. 21, 2018. Accessed Oct. 24, 2019.
- Singer AJ, Thode HC Jr., Viccellio P, et al. The association between length of emergency department boarding and mortality. Acad Emerg Med. 2011;18(12):1324-1329.
- Spirvulis PC, Da Silva JA, Jacobs IG, et al. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust. 2006;184(5):208-212.
- Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust. 2006;184(5):213-216.
- Sun BC, Hsia RY, Weiss RE, et al. Effect of emergency department crowding on outcomes of admitted patients. Ann Emerg Med. 2013;61(6):605-611.e6.
- Bond K, Ospina MB, Blitz S, et al. Frequency, determinants and impact of overcrowding in emergency departments in Canada. Healthc Q. 2007;10(4):32-40.
- Derlet RW, Richards JR. Emergency department crowding in Florida, New York, and Texas. South Med J. 2002;95(8):846-849.
- Kulstad EB, Kelley KM. Overcrowding is associated with delays in percutaneous coronary intervention for acute myocardial infarction. Int J Emerg Med. 2009;2(3):149-154.
- Liu SW, Chang Y, Weissman JS, et al. An empirical assessment of boarding and quality of care: delays in care among chest pain, pneumonia, and cellulitis patients. Acad Emerg Med. 2011;18(12):1339-1348.
- Kulstad EB, Sikka R, Sweis RT, et al. ED overcrowding is associated with an increased frequency of medication errors. Am J Emerg Med. 2010;28(3):304-309.
- Liew D, Liew D, Kennedy MP. Emergency department length of stay independently predicts excess inpatient length of stay. Med J Aust. 2003;179(10):524-526.
- Pines JM, Pollack CV Jr, Diercks DB, et al. The association between emergency department crowding and adverse cardiovascular outcomes in patients with chest pain. Acad Emerg Med. 2009;16(7):617-625.
- Tekwani KL, Kerem Y, Mistry CD, et al. Emergency department crowding is associated with reduced satisfaction scores in patients discharged from the emergency department. West J Emerg Med. 2013;14(1):11-15.
- Medley DB, Morris JE, Stone CK, et al. An association between occupancy rates in the emergency department and rates of violence toward staff. J Emerg Med. 2012;43(4):736-744.
- Innes GD, Sivilotti MLA, Ovens H, et al. Emergency overcrowding and access block: a smaller problem than we think. CJEM. 2019;21(2):177-185.
- Schull MJ, Kiss A, Szalai JP. The effect of low-complexity patients on emergency department waiting times. Ann Emerg Med. 2007;49(3):257-264,264.e1.
- Innes GD. Sorry—we’re full! Access block and accountability failure in the health care system. CJEM. 2015;17(2):171-179.
- Howell E, Bessman E, Kravet S, et al. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149(11):804-811.
- White AL, Armstrong PA, Thakore S. Impact of senior clinical review on patient disposition from the emergency department. Emerg Med J. 2010;27(4):262-265,296.
- Li CJ, Syue YJ, Tsai TC, et al. The impact of emergency physician seniority on clinical efficiency, emergency department resource use, patient outcomes, and disposition accuracy. Medicine (Baltimore). 2016;95(6):e2706.
- Campbell SG, Innes GD, Magee KD, et al. A five-step program for diagnostic test addiction. CJEM 2019;21(5):576-579.
- Schechter MT, Sheps SB. Diagnostic testing revisited: pathways through uncertainty. Can Med Assoc J. 1985;132(7):755-760.
- Morton MJ, DeAugustinis ML, Velasquez CA, et al. Developments in surge research priorities: a systematic review of the literature following the Academic Emergency Medicine Consensus Conference, 2007-2015. Acad Emerg Med. 2015;22(11):1235-1252.
- Litvak E, Fineberg HV. Smoothing the way to high quality, safety and economy. N Engl J Med. 2013;369(17):1581-1583.