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Emergency Department Crowding

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Publication Date: June 2008

Publisher(s): Robert Wood Johnson Foundation

Topic: Health (Hospitals and other health care facilities)


On June 14, 2006, the Institute of Medicine released a series of reports illustrating that the nation's emergency medical system is overburdened, underfunded and highly fragmented. As a result, patients must wait hours or even days for a hospital bed in many areas. One of three reports, Hospital-Based Emergency Care: At the Breaking Point, investigates the epidemic of overcrowded emergency departments and trauma centers across the nation and the effects on the entire health care system. Below are key findings from the report.

Emergency Department (ED) Crowding and Patient Flow
ED utilization in the United States increased by 18 percent from 1992 to 2004, while the number of hospital EDs decreased by 12 percent. Many cities are now reporting dramatic increases in ED wait times and ambulance diversions, with implications for the health and health care of millions. In an April 2002 national survey, 62 percent of all U.S. hospitals reported being "at" or "over" operating capacity, with this proportion rising to 79 percent for urban hospitals and 87 percent for Level I trauma centers.

The rising number of uninsured, an aging population, changing financial incentives and variations in medical practice all contribute to the ED crowding phenomenon. Patients entering the ED may also be sicker than they were in the past. One recent study found a 59 percent increase in the number of critical visits per ED in California from 1990 to 1999. Other factors that play a role in ED crowding include difficulties in recruiting and retaining qualified professional staff, shortages of willing on-call medical specialists, and the overall shrinkage of inpatient hospital capacity. Crowding reflects inefficiencies in community-based health care, the emergency department and the hospital.

Urgent Matters, a national program of the Robert Wood Johnson Foundation, worked to address the issue of ED crowding through its educational and research activities.

A Model for Examining EDs
The "input/throughput/output" model (see figure below) provides a structure for examining the factors that affect ED access, quality and outcomes.

* Input factors include why more people are presenting to EDs, e.g., the aging population, availability of alternative sites of care, insurance status and perceptions of quality.
* Throughput focuses on the actual operations of the ED, e.g., the design of ED processes, timely availability of medical specialists and ancillary services, and accessible clinical information.
* Output factors include the ability to transfer or discharge ED patients, e.g., moving patients into critical care or other inpatient units or transferring patients to follow-up care in the community.


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