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

Systematic Review of Emergency Department Crowding: Causes, Effects, and Solutions

  • Nathan R. Hoot, PhD

      Affiliations

    • Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
    • Corresponding Author InformationAddress for correspondence: Nathan R. Hoot, PhD, 400 Eskind Biomedical Library, 2209 Garland Avenue, Nashville, TN 37232; 615-936-3720, fax 615-936-1427
    • ,
  • Dominik Aronsky, MD, PhD

      Affiliations

    • Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
    • Department of Emergency Medicine Vanderbilt University Medical Center, Nashville, TN.

Received 16 July 2007 ,Revised 26 January 2008 ,Accepted 11 March 2008.

References 

  1. Yamane K. Hospital Emergency Departments: Crowded Conditions Vary Among Hospitals and Communities. Washington, DC: US General Accounting Office; 2003;GAO-03-460
  2. Committee on the Future of Emergency Care in the United States Health System. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: National Academies Press; 2006;
  3. Gibbs N. Do you want to die? (The crisis in emergency care is taking its toll on doctors, nurses, and patients). Time. 1990;58–65May 28,
  4. Barrero J. Hospitals get orders to reduce crowding in emergency rooms. New York Times. 1989;1–2January 24,
  5. Goldberg C. Emergency crews worry as hospitals say, “No vacancy.”. New York Times. 2000;39:December 17
  6. Orenstein JB. State of emergency. Washington Post. 2001;B1:April 22
  7. Jeffrey NA. Who's crowding emergency rooms? (Right now it's managed-care patients). Wall Street Journal. 1999;B1:July 20
  8. Emergency Medical Treatment and Active Labor Act, established under the Consolidated Omnibus Budget Reconciliation Act of 1985. Pub L No. 99-272, 42USC 1395dd (1986).
  9. Asplin BR. Tying a knot in the unraveling health care safety net. Acad Emerg Med. 2001;8:1075–1079
  10. American Academy of Pediatrics Committee on Pediatric Emergency Medicine. Overcrowding crisis in our nation's emergency departments: is our safety net unraveling?. Pediatrics. 2004;114:878–888
  11. Kellermann AL. Crisis in the emergency department. N Engl J Med. 2006;355:1300–1303
  12. Hwang U, Concato J. Care in the emergency department: how crowded is overcrowded?. Acad Emerg Med. 2004;11:1097–1101
  13. Pham JC, Patel R, Millin MG, et al. The effects of ambulance diversion: a comprehensive review. Acad Emerg Med. 2006;13:1220–1227
  14. American College of Emergency Physicians. Crowding. Ann Emerg Med. 2006;47:585
  15. Sackett DL, Haynes RB, Guyatt GH. Clinical Epidemiology: A Basic Science for Clinical Medicine. 2nd ed.. Boston, MA: Little Brown; 1991;
  16. Wang CS, FitzGerald JM, Schulzer M, et al. Does this dyspneic patient in the emergency department have congestive heart failure?. JAMA. 2005;294:1944–1956
  17. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159–174
  18. Asplin BR, Magid DJ, Rhodes KV, et al. A conceptual model of emergency department crowding. Ann Emerg Med. 2003;42:173–180
  19. Grumbach K, Keane D, Bindman A. Primary care and public emergency department overcrowding. Am J Public Health. 1993;83:372–378
  20. Afilalo J, Marinovich A, Afilalo M, et al. Nonurgent emergency department patient characteristics and barriers to primary care. Acad Emerg Med. 2004;11:1302–1310
  21. Howard MS, Davis BA, Anderson C, 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;31:429–435
  22. Sprivulis P, Grainger S, Nagree Y. Ambulance diversion is not associated with low acuity patients attending Perth metropolitan emergency departments. Emerg Med Australas. 2005;17:11–15
  23. Huang JA, Tsai WC, Chen YC, et al. Factors associated with frequent use of emergency services in a medical center. J Formos Med Assoc. 2003;102:222–228
  24. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter?. J Health Soc Behav. 1995;36:1–10
  25. Dent AW, Phillips GA, Chenhall AJ, et al. The heaviest repeat users of an inner city emergency department are not general practice patients. Emerg Med (Fremantle). 2003;15:322–329
  26. Glaser CA, Gilliam S, Thompson WW, et al. Medical care capacity for influenza outbreaks, Los Angeles. Emerg Infect Dis. 2002;8:569–574
  27. Schull MJ, Mamdani MM, Fang J. Influenza and emergency department utilization by elders. Acad Emerg Med. 2005;12:338–344
  28. Schull MJ, Mamdani MM, Fang J. Community influenza outbreaks and emergency department ambulance diversion. Ann Emerg Med. 2004;44:61–67
  29. Andersson G, Karlberg I. 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;55:187–207
  30. Fatovich DM, Hirsch RL. Entry overload, emergency department overcrowding, and ambulance bypass. Emerg Med J. 2003;20:406–409
  31. Baer RB, Pasternack JS, Zwemer FL. Recently discharged inpatients as a source of emergency department overcrowding. Acad Emerg Med. 2001;8:1091–1094
  32. Lambe S, Washington DL, Fink A, et al. Waiting times in California's emergency departments. Ann Emerg Med. 2003;41:35–44
  33. Schneider SM, Gallery ME, Schafermeyer R, et al. Emergency department crowding: a point in time. Ann Emerg Med. 2003;42:167–172
  34. Schull MJ, Lazier K, Vermeulen M, et al. Emergency department contributors to ambulance diversion: a quantitative analysis. Ann Emerg Med. 2003;41:467–476
  35. Lambe S, Washington DL, Fink A, et al. Trends in the use and capacity of California's emergency departments, 1990-1999. Ann Emerg Med. 2002;39:389–396
  36. Polevoi SK, Quinn JV, Kramer NR. Factors associated with patients who leave without being seen. Acad Emerg Med. 2005;12:232–236
  37. Davis B, Sullivan S, Levine A, et al. Factors affecting ED length-of-stay in surgical critical care patients. Am J Emerg Med. 1995;13:495–500
  38. Andrulis DP, Kellermann A, Hintz EA, et al. Emergency departments and crowding in United States teaching hospitals. Ann Emerg Med. 1991;20:980–986
  39. Fromm RE, Gibbs LR, McCallum WG, et al. Critical care in the emergency department: a time-based study. Crit Care Med. 1993;21:970–976
  40. Fatovich DM, Nagree Y, Sprivulis P. Access block causes emergency department overcrowding and ambulance diversion in Perth, Western Australia. Emerg Med J. 2005;22:351–354
  41. Cooke MW, Wilson S, Halsall J, et al. Total time in English accident and emergency departments is related to bed occupancy. Emerg Med J. 2004;21:575–576
  42. Schull MJ, Szalai JP, Schwartz B, et al. Emergency department overcrowding following systematic hospital restructuring: trends at twenty hospitals over ten years. Acad Emerg Med. 2001;8:1037–1043
  43. Forster AJ, Stiell I, Wells G, et al. The effect of hospital occupancy on emergency department length of stay and patient disposition. Acad Emerg Med. 2003;10:127–133
  44. Hwang JI. The relationship between hospital capacity characteristics and emergency department volumes in Korea. Health Policy. 2006;79:274–283
  45. Warden CR, Bangs C, Norton R, et al. Temporal trends in ambulance diversion in a mid-sized metropolitan area. Prehosp Emerg Care. 2003;7:109–113
  46. Sun BC, Mohanty SA, Weiss R, et al. Effects of hospital closures and hospital characteristics on emergency department ambulance diversion, Los Angeles County, 1998 to 2004. Ann Emerg Med. 2006;47:309–316
  47. Derlet RW, Richards JR. Emergency department overcrowding in Florida, New York, and Texas. South Med J. 2002;95:846–849
  48. Derlet R, Richards J, Kravitz R. Frequent overcrowding in U.S. emergency departments. Acad Emerg Med. 2001;8:151–155
  49. Richards JR, Navarro ML, Derlet RW. Survey of directors of emergency departments in California on overcrowding. West J Med. 2000;172:385–388
  50. Clark K, Normile LB. 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. 2002;28:489–495
  51. Bazzoli GJ, Brewster LR, Liu G, et al. Does U.S. hospital capacity need to be expanded?. Health Aff (Millwood). 2003;22:40–54
  52. Miro O, Antonio MT, Jimenez S, et al. Decreased health care quality associated with emergency department overcrowding. Eur J Emerg Med. 1999;6:105–107
  53. Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust. 2006;184:213–216
  54. Sprivulis 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;184:208–212
  55. Begley CE, Chang Y, Wood RC, et al. Emergency department diversion and trauma mortality: evidence from Houston, Texas. J Trauma. 2004;57:1260–1265
  56. Neely KW, Norton RL, Young GP. The effect of hospital resource unavailability and ambulance diversions on the EMS system. Prehosp Disaster Med. 1994;9:172–176
  57. Redelmeier DA, Blair PJ, Collins WE. No place to unload: a preliminary analysis of the prevalence, risk factors, and consequences of ambulance diversion. Ann Emerg Med. 1994;23:43–47
  58. Schull MJ, Morrison LJ, Vermeulen M, et al. Emergency department gridlock and out-of-hospital delays for cardiac patients. Acad Emerg Med. 2003;10:709–716
  59. Schull MJ, Morrison LJ, Vermeulen M, et al. Emergency department overcrowding and ambulance transport delays for patients with chest pain. CMAJ. 2003;168:277–283
  60. Liu S, Hobgood C, Brice JH. Impact of critical bed status on emergency department patient flow and overcrowding. Acad Emerg Med. 2003;10:382–385
  61. Schull MJ, Vermeulen M, Slaughter G, et al. Emergency department crowding and thrombolysis delays in acute myocardial infarction. Ann Emerg Med. 2004;44:577–585
  62. Hwang U, Richardson LD, Sonuyi TO, et al. The effect of emergency department crowding on the management of pain in older adults with hip fracture. J Am Geriatr Soc. 2006;54:270–275
  63. Chen EH, Mills AM, Lee BY, et al. The impact of a concurrent trauma alert evaluation on time to head computed tomography in patients with suspected stroke. Acad Emerg Med. 2006;13:349–352
  64. Burt CW, McCaig LF, Valverde RH. Analysis of ambulance transports and diversions among US emergency departments. Ann Emerg Med. 2006;47:317–326
  65. Kyriacou DN, Ricketts V, Dyne PL, et al. A 5-year time study analysis of emergency department patient care efficiency. Ann Emerg Med. 1999;34:326–335
  66. Weiss SJ, Ernst AA, Derlet R, et al. 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. 2005;23:288–294
  67. Baker DW, Stevens CD, Brook RH. Patients who leave a public hospital emergency department without being seen by a physician (Causes and consequences). JAMA. 1991;266:1085–1090
  68. Rowe BH, Channan P, Bullard M, et al. Characteristics of patients who leave emergency departments without being seen. Acad Emerg Med. 2006;13:848–852
  69. Bindman AB, Grumbach K, Keane D, et al. Consequences of queuing for care at a public hospital emergency department. JAMA. 1991;266:1091–1096
  70. Bayley MD, Schwartz JS, Shofer FS, et al. The financial burden of emergency department congestion and hospital crowding for chest pain patients awaiting admission. Ann Emerg Med. 2005;45:110–117
  71. Krochmal P, Riley TA. Increased health care costs associated with ED overcrowding. Am J Emerg Med. 1994;12:265–266
  72. Eckstein M, Chan LS. The effect of emergency department crowding on paramedic ambulance availability. Ann Emerg Med. 2004;43:100–105
  73. Rondeau KV, Francescutti LH. Emergency department overcrowding: the impact of resource scarcity on physician job satisfaction. J Healthc Manag. 2005;50:327–340
  74. Bucheli B, Martina B. Reduced length of stay in medical emergency department patients: a prospective controlled study on emergency physician staffing. Eur J Emerg Med. 2004;11:29–34
  75. Donald KJ, Smith AN, Doherty S, et al. Effect of an on-site emergency physician in a rural emergency department at night. Rural Remote Health. 2005;5:380
  76. Shaw KN, Lavelle JM. VESAS: a solution to seasonal fluctuations in emergency department census. Ann Emerg Med. 1998;32:698–702
  77. Bazarian JJ, Schneider SM, Newman VJ, et al. Do admitted patients held in the emergency department impact the throughput of treat-and-release patients?. Acad Emerg Med. 1996;3:1113–1118
  78. Kelen GD, Scheulen JJ, Hill PM. Effect of an emergency department (ED) managed acute care unit on ED overcrowding and emergency medical services diversion. Acad Emerg Med. 2001;8:1095–1100
  79. Moloney ED, Bennett K, O'Riordan D, et al. Emergency department census of patients awaiting admission following reorganisation of an admissions process. Emerg Med J. 2006;23:363–367
  80. Ross MA, Naylor S, Compton S, et al. Maximizing use of the emergency department observation unit: a novel hybrid design. Ann Emerg Med. 2001;37:267–274
  81. McConnell KJ, Richards CF, Daya M, et al. Effect of increased ICU capacity on emergency department length of stay and ambulance diversion. Ann Emerg Med. 2005;45:471–478
  82. Dunn R. Reduced access block causes shorter emergency department waiting times: an historical control observational study. Emerg Med (Fremantle). 2003;15:232–238
  83. Miro O, Sanchez M, Espinosa G, et al. Analysis of patient flow in the emergency department and the effect of an extensive reorganisation. Emerg Med J. 2003;20:143–148
  84. Lee-Lewandrowski E, Corboy D, Lewandrowski K, et al. Implementation of a point-of-care satellite laboratory in the emergency department of an academic medical center (Impact on test turnaround time and patient emergency department length of stay). Arch Pathol Lab Med. 2003;127:456–460
  85. Washington DL, Stevens CD, Shekelle PG, et al. Next-day care for emergency department users with nonacute conditions (A randomized, controlled trial). Ann Intern Med. 2002;137:707–714
  86. Derlet RW, Nishio D, Cole LM, et al. Triage of patients out of the emergency department: three-year experience. Am J Emerg Med. 1992;10:195–199
  87. Diesburg-Stanwood A, Scott J, Oman K, et al. 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. 2004;30:312–317
  88. Lagoe RJ, Hunt RC, Nadle PA, et al. Utilization and impact of ambulance diversion at the community level. Prehosp Emerg Care. 2002;6:191–198
  89. Scheulen JJ, Li G, Kelen GD. Impact of ambulance diversion policies in urban, suburban, and rural areas of Central Maryland. Acad Emerg Med. 2001;8:36–40
  90. Vilke GM, Brown L, Skogland P, et al. Approach to decreasing emergency department ambulance diversion hours. J Emerg Med. 2004;26:189–192
  91. Patel PB, Derlet RW, Vinson DR, et al. Ambulance diversion reduction: the Sacramento solution. Am J Emerg Med. 2006;24:206–213
  92. Vilke GM, Castillo EM, Metz MA, et al. Community trial to decrease ambulance diversion hours: the San Diego county patient destination trial. Ann Emerg Med. 2004;44:295–303
  93. Sprivulis P, Gerrard B. Internet-accessible emergency department workload information reduces ambulance diversion. Prehosp Emerg Care. 2005;9:285–291
  94. Shah MN, Fairbanks RJ, Maddow CL, et al. Description and evaluation of a pilot physician-directed emergency medical services diversion control program. Acad Emerg Med. 2006;13:54–60
  95. Haines CJ, Lutes RE, Blaser M, et al. Paramedic initiated non-transport of pediatric patients. Prehosp Emerg Care. 2006;10:213–219
  96. Michelen W, Martinez J, Lee A, et al. Reducing frequent flyer emergency department visits. J Health Care Poor Underserved. 2006;17(1 suppl):59–69
  97. Lee KH, Davenport L. Can case management interventions reduce the number of emergency department visits by frequent users?. Health Care Manag (Frederick). 2006;25:155–159
  98. Bernstein SL, Verghese V, Leung W, et al. Development and validation of a new index to measure emergency department crowding. Acad Emerg Med. 2003;10:938–942
  99. Weiss SJ, Derlet R, Arndahl J, et al. Estimating the degree of emergency department overcrowding in academic medical centers: results of the National ED Overcrowding Study (NEDOCS). Acad Emerg Med. 2004;11:38–50
  100. Reeder TJ, Burleson DL, Garrison HG. The overcrowded emergency department: a comparison of staff perceptions. Acad Emerg Med. 2003;10:1059–1064
  101. Epstein SK, Tian L. Development of an emergency department work score to predict ambulance diversion. Acad Emerg Med. 2006;13:421–426
  102. Weiss SJ, Ernst AA, Nick TG. Comparison of the National Emergency Department Overcrowding Scale and the Emergency Department Work Index for quantifying emergency department crowding. Acad Emerg Med. 2006;13:513–518
  103. Raj K, Baker K, Brierley S, et al. National Emergency Department Overcrowding Study tool is not useful in an Australian emergency department. Emerg Med Australas. 2006;18:282–288
  104. Weiss SJ, Arndahl J, Ernst AA, et al. Development of a site sampling form for evaluation of ED overcrowding. Med Sci Monit. 2002;8:CR549–CR553
  105. Solberg LI, Asplin BR, Weinick RM, et al. Emergency department crowding: consensus development of potential measures. Ann Emerg Med. 2003;42:824–834
  106. Connelly LG, Bair AE. Discrete event simulation of emergency department activity: a platform for system-level operations research. Acad Emerg Med. 2004;11:1177–1185
  107. Chin L, Fleisher G. Planning model of resource utilization in an academic pediatric emergency department. Pediatr Emerg Care. 1998;14:4–9
  108. Cameron P, Scown P, Campbell D. Managing access block. Aust Health Rev. 2002;25:59–68
  109. Lagoe RJ, Kohlbrenner JC, Hall LD, et al. Reducing ambulance diversion: a multihospital approach. Prehosp Emerg Care. 2003;7:99–108
  110. Schneider S, Zwemer F, Doniger A, et al. Rochester, New York: a decade of emergency department overcrowding. Acad Emerg Med. 2001;8:1044–1050
  111. Cardin S, Afilalo M, Lang E, et al. Intervention to decrease emergency department crowding: does it have an effect on return visits and hospital readmissions?. Ann Emerg Med. 2003;41:173–185
  112. Salazar A, Corbella X, Sanchez JL, et al. How to manage the ED crisis when hospital and/or ED capacity is reaching its limits (Report about the implementation of particular interventions during the Christmas crisis). Eur J Emerg Med. 2002;9:79–80
  113. Schull MJ, Kiss A, Szalai JP. The effect of low-complexity patients on emergency department waiting times. Ann Emerg Med. 2007;49:257–264
  114. Siddharthan K, Jones WJ, Johnson JA. A priority queuing model to reduce waiting times in emergency care. Int J Health Care Qual Assur. 1996;9:10–16
  115. Gross D, Harris CM. Fundamentals of Queuing Theory. New York, NY: Wiley; 1985;

 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.

PII: S0196-0644(08)00606-9

doi: 10.1016/j.annemergmed.2008.03.014

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

Article Tools

* Image Usage & Resolution