Crowding

Revised April 2019, February 2013 

Originally approved 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 continued growth in ED visits, which has outpaced population growth. Current trends show increasing patient acuity, requiring more complex evaluation and treatment plans that increase ED care delivery times as well as 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, nursing care, and access to support services such as radiology, laboratory and environmental services. 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, resulting in a loss of privacy for patients and families.
• Treatment of boarded patients, including mental health and ICU patients, by ED nurses.
• Increased morbidity and mortality for both boarded and ED patients.
• Increased disability in older patients who are discharged to facilities rather than admitted.
• Increased length of stay for admitted patients.
• Decreased patient satisfaction for hospitalized and ED patients.
• Diminished ED staff satisfaction and employee engagement.
• Significant delay in evaluation and treatment of emergency patients.
• Patients leaving prior to completion of medical treatment.
• Increased ambulance diversion time.
• Increased stress for behavioral health patients due to a lack of facilities or privacy that are a necessary component of emergency psychiatric care.
• Increased costs for care delivery.
• Reputation damage for the entire institution. 

It is the responsibility of hospital leadership and care providers to quantifiably measure, analyze, and address identifiable and recurrent causes of crowding (such as the predictable saturation of inpatient bed capacity and essential support services) in order to prevent poor outcomes related to crowding. It is recommended that hospital leadership utilize a crowding assessment tool to consistently quantify saturation events and analyze data to identify specific mitigation actions that involve the entire hospital. 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 or placed into observation status at the facility but has not been transferred to an inpatient or observation unit.