Strategies to reduce emergency department overcrowding

Guo B, Harstall C
Record ID 32006000677
Authors' objectives: This report aims to identify strategies that have been evaluated and reported in the literature and to assess their effectiveness in reducing emergency department (ED) overcrowding.
Authors' results and conclusions: Two systematic reviews and 23 primary studies met the inclusion criteria. The two systematic reviews suggested that interventions, such as the presence of a social worker at the ED, cost sharing/co-payment, or primary gate-keeping, might be effective in reducing unnecessary ED attendance; however, concerns remained about the safety of these interventions because the decrease in ED attendance was not restricted to non-urgent patients. Both reviews found that patient education was not effective in terms of reducing ED attendance. In the 23 primary studies included in this report, the majority of the strategies addressed the contributing factors within the ED, with very little research focusing on strategies in the domain of community. Interventions were targeted at ED throughput components, such as ED staffing/reorganization (additional staff and space, improvement in ED flow process), ED acute care unit, fast track, and access to diagnostic services (advanced triage, implementation of point-of-care testing). On the basis of evidence from three studies with better design (RCT or non-randomized comparative studies) and nine before-and-after studies with acceptable methodological quality selected from the 23 studies, some strategies looked promising in terms of decreasing ED demand, improving ED throughputs, decreasing access block, and establishing system-wide change. The strategy for decreasing ED demand included pre-emptive ambulance distribution based on real-time information on access-block ED occupancy. Strategies aimed at improving ED throughput included extensive structural and staff reorganization of the ED, change in provider staffing based on a queueing analysis, implementation of a multidisciplinary care coordination team, addition of a faculty member to ED triage, provision of an on-site emergency physician on the night shift, addition of an acute care unit staffed by ED personnel, implementation of point-of-care tests in the ED, and triage nurse's initiation of appropriate diagnostic tests. Strategies aimed at decreasing access block included increased intensive care unit (ICU) beds. Strategies aimed at system-wide change to decrease ED overcrowding included increased emergency physician coverage, designation of physician coordinators, and introduction of new hospital policy and sharing of process differences among hospitals in a large multi-hospital system. The results from all the studies looked promising when taken individually. However, lack of standard definitions for outcome measures, such as ED length of stay or waiting times, makes it difficult to compare the results across studies. Furthermore, the issue of ED overcrowding is a complex and challenging area in which to conduct research. The overall poor methodological quality of the studies prevented any definitive conclusions about the effectiveness of the various strategies examined in these studies.
Authors' recommendations: This report serves as a benchmark of the currently published research and identifies areas for improvement. Standardization of the definitions for ED overcrowding and other relevant terms is essential. Research needs to be conducted on input and output components that are seen to be contributory rather than just on throughput. Identifying the determinants of ED overcrowding needs to involve leaders at all levels within the system from the ED to the community. Strategies to address the determinants need to be evaluated using clinically meaningful measures. Development of valid, reliable, and sensitive outcome measures is important. Adoption of standardized measures by all of the provincial regional health authorities would allow for some comparison of different strategies and the adoption of those that are most effective and efficient province-wide.
Authors' methods: Review
Project Status: Completed
Year Published: 2006
English language abstract: An English language summary is available
Publication Type: Not Assigned
Country: Canada
MeSH Terms
  • Humans
  • Crowding
  • Emergency Service, Hospital
Organisation Name: Institute of Health Economics
Contact Address: 1200, 10405 Jasper Avenue, Edmonton, Alberta, Canada, T5J 3N4. Tel: +1 780 448 4881; Fax: +1 780 448 0018;
Contact Name:
Contact Email:
Copyright: <p>Alberta Heritage Foundation for Medical Research (AHFMR)</p>
This is a bibliographic record of a published health technology assessment from a member of INAHTA or other HTA producer. No evaluation of the quality of this assessment has been made for the HTA database.