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[EMERGENCY DEPARTMENT (ED) OVERCROWDING: EVIDENCE-BASED ANSWERS TO FREQUENTLY ASKED QUESTIONS -Salway RJ MD et al]
visited the ED in one year, with 3% of patients constituting
50% of the ED visits (5).
More recently, there has been far greater emphasis on the
boarding of admitted patients as the primary cause of ED
overcrowding. Admitted patients are left in the ED when
there is no “proper” space within the institution. A number
of studies have shown a direct and strong correlation
between the number of admissions being boarded in the
ED and overcrowding, making it clear beyond question that
this is the number one culprit related to ED overcrowding.
In short, it is not really the ED that is overcrowded, it is the
hospital that is overcrowded.
It is important to distinguish what overcrowding means in
the ED versus the inpatient units in most hospitals. Inpa-
tient units are considered “full” when their normal patient
beds are occupied.
At this juncture, they are considered to be “incapable” of
taking more patients. Emergency departments are consid-
ered “full” when all of their rooms are full, all of their hallway
stretchers are full, and all of their chairs are full. Thus, there
is a striking contrast between the ED and the inpatient units
in their respective views of what constitutes “at capacity.”
Similarly, staffing ratios which may be preserved on the
inpatient units are unachievable in the ED during times of
overcrowding.
WHAT ARE THE CONSEQUENCES OF ED
OVERCROWDING?
A wealth of literature exists that demonstrates the conse-
quences of overcrowding in the ED.
These consequences include the following:
A. Sick people have to wait too long to receive care
In fact, the Centers for Disease Control (CDC) reported that,
for patients judged by the triage nurse to be critical, over
10% of this group waited more than an hour to see a physi-
cian (6). Many illnesses are time-dependent. Horwitz, et al.,
reported on measures relating to ED wait times; only 67%
of acutely ill patients were seen within the recommended
times in the US (7).
Pines, et al., studied the complication rate of patients with
acute coronary syndrome (ACS) as a function of crowded
versus non-crowded conditions, and found a significant
increase in serious complications (approximately 6% vs. 3%
incidence of death, cardiac arrest, heart failure, late myocar-
dial infarction, arrhythmias, stroke, or hypotension) in those
patients presenting during 8 times of overcrowding.
Earlier intervention produces better outcomes.
Late diagnoses may sometimes be too late, with permanent
consequences of disability or death. Waiting times can be
reduced by reducing access block.
B. Boarding increases TOTAL length of stay in the
hospital, further worsening access.
Multiple studies have documented the total hospital length
of stay (LOS) to be a full day longer in patients boarded in
the ED versus patients with similar illnesses promptly placed
on the inpatient unit (9, 10). Conversely, it has been noted
that, when the patient is placed on the inpatient unit via a
full capacity protocol, this effect on LOS is reversed.
C. Boarding increases walkouts, sometimes of patients
needing admission
The longer the wait, the greater the number of people who
leave prior to receiving care. Unfortunately, the percentage
of patients with serious illness differs little in the group
who leave as compared with the group that waits for care. A
number of these walkouts will require subsequent admission
(11-13).
D. Overcrowding reduces the quality of care and
increases medical errors
A number of articles document the impact of overcrowding
on the quality of care and medical error (14). Many errors
are errors of omission, as the emergency staff must focus on
the new emergencies coming in the door (15). Medication
errors have been shown to increase in frequency as over-
crowding occurs (16).
Multiple studies document inferior care rendered during
times of overcrowding. Sills, et al., documented the impact
of overcrowding on the care of asthma or long bone fractures
in children (17). Mills, et al., showed a similar association
between overcrowding and delays to provision of analgesia
for adults with abdominal pain, a problem also identified in
the study by Hwang, et al (18,19) Pines, et al., also demon-
strated the same relationship between overcrowding and
provision of care for painful conditions (20). A review of the
literature in 2009 revealed similar findings (21).
Boarded admissions are at risk of adverse events or errors.
Pines, et al., demonstrated an association between over-
crowding and adverse cardiac events (22). In another paper,
the same group showed the impact of overcrowding on the
timely management of patients with community-acquired
pneumonia (23).
A similar finding was described by authors at UCSF (24).