According to the Centers for Disease Control and Prevention (CDC), approximately 136 million people visit the emergency department (ED) every year — and this number is rising. Of these, roughly 40 million are treated for injuries, and 2.1 million are admitted to the critical care unit. In 2011, 20 percent of adults in the U.S. reported at least one ED visit in the past year, and 7 percent reported two or more visits.

However, while the number of ED visits has increased, while the number of EDs has decreased.

Between 1995 and 2010, annual ED visits in the U.S. grew by 34 percent, while the number of hospitals with EDs declined by 11 percent. In 2010, the number of ED visits involving patients with mental health or substance abuse issues represented about 5 percent of all visits, and these patients were boarded, or kept in the ED after the decision to admit or transfer the patient, twice as long as medical patients.

As of 2015, ED visits continued to climb in the second year of the Affordable Care Act, despite the prediction that ED visits would decline as more people gained access to physicians and other healthcare providers. The national wait time to be seen by an ED physician ranges from 3 hours to more than 4.5 hours, and in some states the average total wait times is close to 7.5 hours.

Clearly, EDs are overcrowded. The causes include lack of inpatient beds, lack of access to primary care physicians, and increasing demand with decreasing supply.

Although there is no one solution for alleviating overcrowding in EDs, a recent study in the Annals of Emergency Medicine identifies four key strategies that have reduced the problem. According to senior author Benjamin Sun, M.D., a professor of emergency medicine in the OHSU School of Medicine, ED overcrowding is dangerous for patients because of delayed pain medications and antibiotics, and the risk of death is higher in more crowded EDs.

In this mixed-methods, comparative case study, researchers used a positive deviance methodology to identify strategies among high-performing, low-performing and high-performance improving hospitals to reduce ED crowding.

They selected and recruited hospitals that were within the top and bottom 5 percent of Centers for Medicare & Medicaid Services case-mix-adjusted ED length of stay and boarding times for admitted patients for 2012. They also recruited hospitals that showed the highest performance improvement in metrics between 2012 and 2013.

The researchers talked to 60 people at the 12 hospitals. Interviewees included nursing staff, ED directors, directors of inpatient services, chief medical officers and other executive officers. Across all hospitals, ED crowding was recognized as a hospitalwide issue.

The strategies for addressing ED crowding varied widely. No specific interventions were associated with performance in length-of-stay metrics. However, four key strategies were identified:

  1. executive leadership involvement
  2. hospitalwide coordinated strategies
  3. data-driven management
  4. performance accountability

Earlier suggestions for resolving ED overcrowding have included reducing ED boarding, increasing primary care access, reducing process time for noncritical patients, improving communication between ED and inpatient units, using online clocks and hotlines so patients can check wait times, and moving patients from EDs to observation units for testing and monitoring before admitting or releasing.

The first EDs, developed in the 1960s, were often simply rooms where hospital doctors took turns treating patients with traumatic, emergent conditions, such as accident victims. By 1980, EDs were the backbone of our national healthcare safety net.

Today, however, ED overcrowding in the U.S. represents an emerging threat to patient safety and could have a significant impact on critically ill patients, who constitute a significant proportion of emergency medicine. Meeting the challenge of ED overcrowding is critical to promoting and ensuring quality patient care services.