Overcrowding in Emergency Department: Comparison
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Overcrowding in Emergency Departments (EDs) is a phenomenon that is now widespread globally and causes a significant negative impact that goes on to affect the entire hospital.

  • overcrowding
  • emergency department
  • hospital admission

1. Introduction

The Emergency Department (ED) is one of the most crowded hospital units, where many patients with various medical conditions, including high-risk patients, are admitted [1]. The main purpose of the ED is to treat emergency and urgent cases that need immediate assistance through a rapid diagnosis and the administration of a medical or surgical treatment in a very short time. It has now been established that the malfunctioning of health services in the community leads to improper access to the ED, especially in the geriatric and pediatric age groups [1][2][3]. ED’s crowding, sometimes referred to as overcrowding, has been identified as a problem for a timely and efficient assistance since the 1980s [4].
Overcrowding can be defined as a situation in which the performance of the emergency department is compromised, mainly due to the excessive number of patients waiting for consultation, diagnosis, treatment, transfer, or discharge [2][5]; overcrowding is characterized by an imbalance between supply and demand [2].
Although many factors contribute to overcrowding, the latter depends essentially on three factors: the incoming volume of patients (input), the time to process and treat patients (throughput), and the volume of patients leaving the ED (output) [6].
Among the different factors, patient boarding was found to be one of the most significant [7]. Boarding is the practice of keeping patients admitted to the ED for prolonged periods due to inadequate capacity of inpatient wards [7][8]. Boarding, and overcrowding in general, has negative effects on patient care, mortality, morbidity, patient satisfaction, and quality of care [4][9][10]. These also contribute to a longer length of stay (LOS) in the ED, an increased rate of patients leaving the ED without being seen (LWBS, left without being seen), and increased medical errors [11][12][13].
ED overcrowding has turned into a serious health problem, as the number of EDs is decreasing, while the number of patients requiring emergency services is increasing [11][13]. It has been reported in the literature that overcrowding occurs most often in EDs with an annual volume of over 40,000 visits [11][14].
An accurate measurement of crowding in the ED and an evidence-based understanding of its impact are essential prerequisites before attempting to find solutions [6]. Although there are various scores for estimating the different degrees of overcrowding, to date, there is still no gold standard for measuring this phenomenon [4][15]. A review in the literature suggests that overcrowding is defined by the following three estimation indices: National Emergency Department Overcrowding Score (NEDOCS), Community Emergency Department Overcrowding Score (CEDOCS), and Severely-overcrowded-Overcrowded and Not-overcrowded Estimation Tool (SONET). The most frequently used score is the NEDOCS, developed by Weiss and colleagues [15]; NEDOCS converts a series of variables into a score, which is related to the degree of overcrowding perceived by the professionals performing their tasks at that moment. The scale has a range between 0 and 200 points, where a rating of 101 or more indicates a condition of overcrowding [16].
Finally, among the measurement systems that can be evaluated to estimate overcrowding, we also have ED occupancy, ED length of stay, ED volume, ED boarding time, number of boarders, waiting room number, and the Emergency Department Work Index (EDWIN) score. So, in order to develop efficient solutions to overcrowding, it is essential not only to understand its various causes and effects but also to estimate its actual impact on the health care system [4].

2. Causes of ED Overcrowding

As anticipated, the problem of overcrowding in EDs can be due to multiple factors, which may be represented by the input–throughput–output model (Table 1). Overcrowding is a multifactorial and complex phenomenon; these different factors are independent from one another but are closely connected and influenced by additional factors [10][17][18].
Table 1. Main causes of overcrowding.
Factors Causes
Input

due to the volume of patients arriving and waiting to be seen		 Presentations with more urgent and complex care needs

• Emergencies
]. Return visit (RV) is often used as a quality indicator for ED because it can be caused by premature discharge, missed diagnosis, or failure of treatment or discharge planning [26]. RVs not only delay adequate treatment of patients, but also increase resource use and medical costs [26][27]. Other factors, such as disease progression, lack of improvement, or patient concern and fear about their condition, contribute to this problem. Overcrowding is a health problem worldwide that leads to an increase in misdiagnoses and medical errors [26][28]. ED staff must always provide timely care to urgent patients; therefore, when the ED is overcrowded, physicians accelerate the patient discharge process to prepare an empty bed for new patients [2].

4. Solution to Overcrowding

Regarding the resolution of overcrowding, several actions are needed, not only at the medical level but also at the bureaucratic level. These can be divided into two levels that act in synergy: microlevel and macrolevel strategies [4][10] as shown schematically in Table 2.
Table 2.  Microlevel and macrolevel strategies.
Strategies Solutions
Microlevel strategies

applied at the level of the Emergency Department		 Acceleration of diagnostic pathways
Increase in presentations by the elderly
High volume of low-acuity presentations (LAPs)
Access to primary care

• The poor and uninsured who lack primary care
Limited access to diagnostic services in community

• The malfunctioning of health care services in the community
Inappropriate use of emergency services

• Unnecessary visits

• “Frequent flyer” patients

• Nonurgent visits

• The majority of ED incomings resulted from

self-referral process
The number of escorts accompanying a patient
Throughput

due to the time to process and/or treat patients		 ED nursing staff shortages

Low staffing and resource levels
Presence of junior medical staff in ED
Delays in receiving test results and delayed disposition decisions
Number of tests (blood test and urinalysis) required to be performed per patient
Too long a consultation time
Patient degree of gravity
Bed availability (both in the ED and in the hospital)
Output

due to the volume of patients leaving the ED		 Boarding
Exit block
Lack of available hospital beds
Inefficient planning of discharging patients
Others An increase in closures of a significant number of EDs
Time of the year

• Influenza season

• Seasonal illness
Weekend, holiday periods
COVID-19

3. Effects and Consequences of Overcrowding in EDs

The most evident effect of overcrowding in the performance of an ED is an increase in patient waiting time; this increase causes an increment in the number of patients leaving the ED before being visited by a physician, which is defined as left without being seen (LWBS); however, it has been observed that this group of patients complains of a progressive worsening of health conditions and returns shortly afterwards to be hospitalized (return visit). Several studies have found that the quality of treatment in overcrowded situations worsens significantly; it has been shown that in patients with myocardial infarction, an increase in door-to-needle time, the time between patient evaluation and drug administration, was significantly longer in overcrowded situations compared to normal timing [2]. An Australian retrospective study showed a clear increase in mortality of patients admitted to the ED during an overcrowded shift compared with those admitted during a normal shift. The authors of this study calculated that there are 13 deaths per year in their hospital due to overcrowding in the ED [19]. Overcrowding reduces ED capacity, affects quality of care, increases the risk of adverse outcomes for patients, especially cardiac and intubated patients, and increases the risk of hospital-acquired infections and the likelihood of patient management errors [20][21]. ED staff also suffer the effects of overcrowding; job satisfaction is affected by these stressful situations, and overcrowding has been identified as a major reason for staff reduction [2][22]. The potential financial impact of overcrowding is not insignificant; in fact, the resulting increase in reconsultations and hospitalizations, worse quality of treatment, dissatisfaction of health care staff, and morbidity lead to higher treatment costs [2][23]. According to a study, boarding increases the cost by USD 6.8 million over 3 years. Reducing boarding time by just one hour would increase revenue by USD 13,298 per day or USD 4.9 million per year [4][24][25
Fast track
Outpatient services outside the ED
Setting home care
Observation unit
Team triage

Artificial intelligence (AI) and machine learning
Macrolevel strategies

applied at the hospital and/or care system level		 Simplifying the admission process
Reverse triage
Smoothing elective admissions
Early discharge
Weekend discharge
Full capacity protocol or action plan
Legislation and guidelines
 

References

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  14. Welch, S.J.; Augustine, J.J.; Dong, L.; Savitz, L.A.; Snow, G.; James, B.C. Volume-Related Differences in Emergency Department Performance. Jt. Comm. J. Qual. Patient Saf. 2012, 38, 395-AP1.
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  16. Boldori, H.M.; Ciconet, R.M.; Viegas, K.; Schaefer, R.; dos Santos, M.N. Cross-Cultural Adaptation of the Scale National Emergency Department Overcrowding Score (NEDOCS) for Use in Brazil. Rev. Gaúcha De Enferm. 2021, 42, e20200185.
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