A study published in the Emergency Medicine Journal (abstract here) aims to provide a tool to accurately measure emergency department overcrowding.

The studies authors recruited an international group of 40 experts with experience in ED overcrowding. Crowding measures submitted by the panel were subsequently evaluated and ranked.
Eventually a set of eight quantified crowding measures was agreed on.

The objective of this study was to prioritise a list of quantified crowding measures, with clearly defined terms and international applicability, that would assess the current state of a department, evaluate how the department is coping with the current demands and highlight areas of concern…..
…. The principle contribution of this study, which progresses the current crowding literature, was the generation of quantifiable measures. These measures provide a more comprehensive view of the ED operations and highlight areas of concern. This knowledge could make a considerable contribution to decision making regarding ED management and provide a basis for learning across different departments. Future work needs to validate these results. Acceptance of these measures will progress this field of research to the point where we can focus on developing targeted methods of management and minimisation of crowding.


The 8 measures of emergency department overcrowding:

Input measures

1. Ability of ambulances to offload

Ambulance offload time is the time between ambulance arrival and offload. An emergency department (ED) is crowded when ambulance offload time is greater than 15 min in more than 10% of cases.

2. Patients who leave without being seen or treated (LWBS)

An ED is crowded when the number of patients who LWBS is greater-than or equal to 5%.

3. Time until triage

An ED is crowded when there is a delay >5 min from a patient’s ED presentation to begin their initial triage.

Throughput measures

4. ED occupancy rate

An occupancy rate is the total volume of patients in the ED compared with the total number of officially designated ED treatment spaces. An ED is crowded when the occupancy rate is >100%.

5. Patients’ total length of stay in the ED

An ED is crowded when more than 10% of patients have a total length of stay >4h.

6. Time to see a physician

An ED is crowded when a patient waits longer than 30 min to be seen by a physician.

Output measures

7. ED boarding time

An ED is crowded when >10% of patients remain in the ED 2 h after the admission decision.

8. Number of patients boarding in the ED

Boarders are admitted patients waiting to be placed in an inpatient bed. An ED is crowded when boarders occupy >10% of the total occupancy.


Why are our emergency departments so overcrowded?

In the last 25 years, the total number of acute public hospital beds in Australia has been cut by one-third from 74,000 beds in 1983 to 56,900 beds in 2009–2010. Adjusted for population growth, there has been a 60% fall from 4.8 public acute beds per 1000 population in 1983 to 2.5 per 1000 population (2.6 per 1000 including psychiatric beds). This includes an 18% decrease between 1995–1996 and 2005–2006.
Excessive bed closures mean public hospitals with significant emergency demand are unable to operate with sufficient spare bed capacity. True average occupancy in many major urban public hospitals is 90–95% and therefore peak demand commonly pushes occupancy over 100%
:: Paul Cunningham: Inadequate acute hospital beds and the limits of primary care and prevention::

3 Responses to “Emergency department overcrowding: a measurement tool.”

  1. Can’t disagree with the content. Perhaps, though, the point would get across more clearly if it was worded in a less ED-centric context? Instead of the “an ED is crowded when…” preface, “a _hospital_ is crowded when…” better illustrates the effect being felt at the ED level. It might stop people from thinking all we need are more ED beds to fix the solution…

    • In reply to gun street girl, it is an ED overcrowding tool, not a hospital overcrowding tool, hence the ED-centricity.

      The output measures (number of boarders and time to ward(board) patients) are the factors relating to the rest of the hospital. If the use of a tool like this can identify times when overcrowding is being perpeutated by output factors then that will give data to demonstrate that it is occupancy/flow/management of the workload and patients in the rest of the hospital that needs action.

      • @Kathy, I’m aware of that. Problem with the wording is that politicians pick up on that, and pledge money to “help the ED”, as though the issue is isolated in the ED. Walk in clinics, telephone hot lines, more ED beds, more ED staff (yada yada) – and very little flow into what the hospital needs most: inpatient beds so we can get the patients out of the ED and into the ward, where they need to be.

        Those of us who work within the system are perpetually frustrated at the focus on ED and surgical waiting lists being used as surrogate markers for hospital “productivity”, because it’s just sending out the wrong message to the public. As insiders, we all understand the problem is far more complex than those stats, but unfortunately the politicians and public alike don’t seem to be picking up on the message.

        The whole system is in crisis, not just the ED. We’re all busy, we’re all tired, and we’re all stretched beyond reasonable measures. It would be really nice to see reports reflect that truth.

        (Apologies if this posted twice!)

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