Emergency Department Overcrowding and Patient Safety

People Waiting For Doctor In Hospital Lobby

The correlation between emergency department crowding and a decline in patient safety is strong. Studies even suggest the risk to patients is twice as great during times of peak traffic, making interventions all the more necessary, considering the consequences to the patient experience.

Despite this study and a few others, there’s a severe shortage of research that reports on the relationship between crowding and patient safety.

In this article published in the Annals of Emergency Medicine, Jesse M. Pines, MD, MBA acknowledges that “the first reports of crowding in US EDs emerged in the late 1980s and early 1990s. Now, more than 20 years later, the first published claims-based, US-based, health services research report links what may seem to an everyday person to be an obviously unsafe environment to negative patient outcomes.” (This study the author alludes to found that patients had a 5-percent higher chance of death if they were admitted on days with increased crowding, along with longer stays, and higher costs per admission.)

Then the author makes another critical observation regarding how the very term, “ED crowding,” is outdated because “one of the main causes of ED crowding is ‘hospital crowding’ and its result: prolonged boarding of admitted patients in the ED.”

So what actions can ED and hospital leaders take to reduce crowding? I’ve written extensively about ways to combat overcrowding by optimizing patient flow and improving communication inside the ED and between departments. Real-time analytics is another important tool that can be used to reduce crowding and shows increasing promise. But the solution many EDs turn to — and, admittedly, the umbrella the tactics mentioned above fall under — is actually adaptation. To put it simply,  for EDs to continue providing high quality care safely and efficiently, they have to adapt to an ever-increasing volume of patients.

Adapting to crowded ED environments and developing ways to work with less than desirable circumstances isn’t discussed very often, as Pines’ article from the Annals of Emergency Medicine points out.

“Another unspoken issue in the relationship between ED and hospital crowding and quality outcomes is that some EDs may have actually adapted to the inhospitable crowded environment and have created safer mechanisms to deal with the dysfunction,” the article states. “These may include adding nurses or techs to the triage area, using point-of-care testing to identify high-risk patients (i.e., troponin or lactate), or creating hospital policies that ensure that patients who are likely to be harmed by crowding (such as boarders) are rapidly evaluated and cared for by inpatient teams in the ED.”

However, just like the dearth of research regarding overcrowding and patient safety, there’s also a lack of discussion regarding the adaptive responses EDs take in response to crowding, which place ED and hospital leaders in a difficult situation — fixing a problem that is ill-defined and understudied, even though the impact is obvious.  

So the question still remains, how do ED leaders, emergency care providers and other stakeholders fix a problem that is so ill-defined and understudied? The case can be made for further studies, specifically of hospitals that have successfully adapted to crowding and those that haven’t.  

How has your ED adapted to increasing patient volumes? Have you successfully reduced crowding in your ED, or are you still working to develop and implement customized solutions? Share what has and hasn’t worked, or feel free to drop me a line to share your experience.


Internal and Emergency Medicine: “Emergency department crowding and risk of preventable medical errors.”

Annals of Emergency Medicine: Emergency Department Crowding in California: A Silent Killer?

Annals of Emergency Medicine: Effect of Emergency Department Crowding on Outcomes of Admitted Patients