Revised and approved by the ACEP Board of Directors February 2013
Originally approved by the ACEP Board of Directors January 2006
Crowding occurs when the identified need for emergency services exceeds available resources for patient care in the emergency department (ED), hospital, or both.
The causes of crowding are multifactorial and span the entire health care delivery system. Research has shown a continued growth in ED visits, which has outpaced population growth. Current trends show increasing patient acuity as well, requiring more complex evaluation and treatment plans that increase care delivery times as well as ED and inpatient lengths of stay. The resultant strain on hospital inpatient bed capacity creates downstream pressure to board admitted patients* in the ED. These factors exacerbate crowding by utilizing limited ED resources including beds and nursing care. Evidence has shown an increase in morbidity and mortality due to boarding.
Results of crowding include:
- Treatment of patients in areas not designated for treatment, such as hallways.
- Treatment of boarded inpatients by outpatient (ED) nurses.
- Increased morbidity and mortality for both boarded and other ED patients.
- Increased disability in older patients who are discharged to facilities rather than admitted.
- Increased inpatient length of stay.
- Decreased patient satisfaction.
- Significant delay in evaluation and treatment of emergency patients.
- Patients leaving prior to completion of medical treatment.
- Increased ambulance diversion time.
- Increased costs.
It is the responsibility of hospital leadership to address well-identified recurrent causes of crowding (such as unavailability of inpatient beds) in order to prevent poor outcomes related to crowding. It is imperative that local and national health care systems are active in addressing the more global and systemic causes of crowding, including hospital funding. Emergency medicine leadership should be actively involved in helping to identify successful solutions to crowding at both the local and national levels.
* A “boarded patient” is defined as a patient who remains in the emergency department after the patient has been admitted to the facility, but has not been transferred to an inpatient unit.