Background: An Institute of Medicine (IOM) report defines six domains of quality of care: safety, patient-centeredness, timeliness, efficiency, effectiveness, and equity. The effect of emergency department (ED) crowding on these domains of quality has not been comprehensively evaluated.

Objectives:  The objective was to review the medical literature addressing the effects of ED crowding on clinically oriented outcomes (COOs).

Methods:  We reviewed the English-language literature for the years 1989–2007 for case series, cohort studies, and clinical trials addressing crowding’s effects on COOs. Keywords searched included “ED crowding,”“ED overcrowding,”“mortality,”“time to treatment,”“patient satisfaction,”“quality of care,” and others.

Results:  A total of 369 articles were identified, of which 41 were kept for inclusion. Study quality was modest; most articles reflected observational work performed at a single institution. There were no randomized controlled trials. ED crowding is associated with an increased risk of in-hospital mortality, longer times to treatment for patients with pneumonia or acute pain, and a higher probability of leaving the ED against medical advice or without being seen. Crowding is not associated with delays in reperfusion for patients with ST-elevation myocardial infarction. Insufficient data were available to draw conclusions on crowding’s effects on patient satisfaction and other quality endpoints.

Conclusions:  A growing body of data suggests that ED crowding is associated both with objective clinical endpoints, such as mortality, as well as clinically important processes of care, such as time to treatment for patients with time-sensitive conditions such as pneumonia. At least two domains of quality of care, safety and timeliness, are compromised by ED crowding.

https://www.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1553-2712.2008.00295.x

The effect of emergency department crowding on clinically oriented outcomes

https://nuhem.com/emlinks/LLSA%20Articles%202015/Lean%20Thinking%20in%20ED.pdf

Lean Thinking in Emergency Departments : A Critical Review

Objectives: While emergency department (ED) crowding is a worldwide problem, few studies havedemonstrated associations between crowding and outcomes. The authors examined whether ED crowd-ing was associated with adverse cardiovascular outcomes in patients with chest pain syndromes (chestpain or related complaints of possible cardiac origin).Methods: A retrospective analysis was performed for patients ‡30 years of age with chest pain syn-drome admitted to a tertiary care academic hospital from 1999 through 2006. The authors comparedrates of inpatient adverse outcomes from ED triage to hospital discharge, deﬁned as delayed acute myo-cardial infarction (AMI), heart failure, hypotension, dysrhythmias, and cardiac arrest, which occurredafter ED arrival using ﬁve separate crowding measures.Results: Among 4,574 patients, 251 (4%) patients developed adverse outcomes after ED arrival; 803(18%) had documented acute coronary syndrome (ACS), and of those, 273 (34%) had AMI. Compared toless crowded times, ACS patients experienced more adverse outcomes at the highest waiting room cen-sus (odds ratio [OR] = 3.7, 95% conﬁdence interval [CI] = 1.3 to 11.0) and patient-hours (OR = 5.2, 95%CI = 2.0 to 13.6) and trended toward more adverse outcomes during time of high ED occupancy(OR = 3.1, 95% CI = 1.0 to 9.3). Adverse outcomes were not signiﬁcantly more frequent during timeswith the highest number of admitted patients (OR = 1.6, 95% CI = 0.6 to 4.1) or the highest trailing meanlength of stay (LOS) for admitted patients transferred to inpatient beds within 6 hours (OR = 1.5, 95%CI = 0.5 to 4.0). Patients with non-ACS chest pain experienced more adverse outcomes during the high-est waiting room census (OR = 3.5, 95% CI = 1.4 to 8.4) and patient-hours (OR = 4.3, 95% CI = 2.6 to7.3), but not occupancy (OR = 1.8, 95% CI = 0.9 to 3.3), number of admitted patients (OR = 0.6, 95% CI0.4 to 1.1), or trailing LOS for admitted patients (OR = 1.2, 95% CI = 0.6 to 2.0).Conclusions: Therewasanassociationbetween some measures ofEDcrowdinganda higher risk of adversecardiovascular outcomes in patients withbothACS-related and non–ACS-related chest pain syndrome.ACADEMIC EMERGENCY MEDICINE 2009; 16:617–625 a 2009 by the Society for Academic EmergencyMedicineKeywords: crowding, overcrowding, adverse outcomes, cardiovascular, emergency department,health care

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1553-2712.2009.00456.x

The association between emergency department crowding and adverse cardiovascular outcomes in patients with chest pain.

Forecasting emergency department crowding: a discrete event simulation.

ACADEMIC EMERGENCY MEDICINE 2011; 18:527–538 © 2011 by the Society for Academic Emergency Medicine

Abstract
Objectives:  Despite consensus regarding the conceptual foundation of crowding, and increasing research on factors and outcomes associated with crowding, there is no criterion standard measure of crowding. The objective was to conduct a systematic review of crowding measures and compare them in conceptual foundation and validity.

Methods:  This was a systematic, comprehensive review of four medical and health care citation databases to identify studies related to crowding in the emergency department (ED). Publications that “describe the theory, development, implementation, evaluation, or any other aspect of a ‘crowding measurement/definition’ instrument (qualitative or quantitative)” were included. A ”measurement/definition” instrument is anything that assigns a value to the phenomenon of crowding in the ED. Data collected from papers meeting inclusion criteria were: study design, objective, crowding measure, and evidence of validity. All measures were categorized into five measure types (clinician opinion, input factors, throughput factors, output factors, and multidimensional scales). All measures were then indexed to six validation criteria (clinician opinion, ambulance diversion, left without being seen (LWBS), times to care, forecasting or predictions of future crowding, and other).

Results:  There were 2,660 papers identified by databases; 46 of these papers met inclusion criteria, were original research studies, and were abstracted by reviewers. A total of 71 unique crowding measures were identified. The least commonly used type of crowding measure was clinician opinion, and the most commonly used were numerical counts (number or percentage) of patients and process times associated with patient care. Many measures had moderate to good correlation with validation criteria.

Conclusions:  Time intervals and patient counts are emerging as the most promising tools for measuring flow and nonflow (i.e., crowding), respectively. Standardized definitions of time intervals (flow) and numerical counts (nonflow) will assist with validation of these metrics across multiple sites and clarify which options emerge as the metrics of choice in this “crowded” field of measures.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1553-2712.2011.01054.x

Measures of Crowding in the Emergency Department: A Systematic Review

OBJECTIVES: Admission process delays and other throughput inefficiencies are a leading cause of emergency department (ED) overcrowding, ambulance diversion, and patient elopements. Hospital capacity constraints reduce the number of treatment beds available to provide revenue-generating patient services. The objective of this study was to develop a practical method for quantifying the revenues that are potentially lost as a result of patient elopements and ambulance diversion. METHODS: Historical data from 62,588 patient visits to the ED of a 450-bed nonprofit community teaching hospital in central Pennsylvania between July 2004 and June 2005 were used to estimate the value of potential patient visits foregone as a result of ambulance diversion and patients leaving the ED without treatment. RESULTS: The study hospital may have lost 3,881,506 dollars in net revenue as a result of ambulance diversions and patient elopements from the ED during a 12-month period. CONCLUSIONS: Significant revenue may be foregone as a result of throughput delays that prevent the ED from utilizing its existing bed capacity for additional patient visits. Language: en

https://onlinelibrary.wiley.com/doi/pdf/10.1197/j.aem.2006.06.056

The financial impact of ambulance diversions and patient elopements.

Time Value Stream Mapping As a Tool to Measure Patient Flow Through Emergency Department Triage

We show that automated external defibrillation training of emergency medical technicians (EMTs) is less time consuming than manual defibrillation training, and hypothesize that both improve survival from sudden cardiac death Data on 91 cardiac arrests over 27 months among five basic life support services was collected before EMT-defibrillation (EMT-D) training Subsequently, seven BLS services were trained in EMT-D using either manual defibrillation or automated external defibrillation technology, and 55 sudden cardiac death patients were entered after training Manual defibrillation required 11 more hours per student in initial training Survival to hospital discharge improved from two of 91 patients (22%) in the series before EMT-D training to nine of 55 patients (164%) after EMT-D training (P = 001) Improved survival was correlated with shorter prehospital defibrillation times, 884 minutes, when EMTs performed defibrillation versus 163 minutes before training when EMTs awalted advanced life support defibrillation (P < 001) To enhance equipment famillarity we allowed EMTs to apply three-lead electrode monitors to all medical/cardiac patients during transport (surveillance) There were six emergency medical service-witnessed “surveillance” arrests and three arrests survived to hospital discharge (50% survival) This group represented 33% of all survivors in the series We recommend automated external defibrillation training for EMTs Improved survival in sudden cardiac death cases in well-run emergency medical service systems should result from EMT-D training Finally, we recommend that routine “surveillance” of high-risk patients during transport by defibrillation-capable EMTs be considered in EMT-D programs, rather than limiting EMT-D only to units capable of rapid “man-down” response

An evaluation of automated defibrillation and manual defibrillation by emergency medical technicians in a rural setting

Objectives: Boarding admitted patients in emergency department (ED) treatment beds has been recognized as a major cause of ED crowding and ambulance diversions. When process delays impede the transfer of admitted patients from the ED to inpatient units, the department's capacity to accept new arrivals and to generate revenue from additional patient services is restricted. The objective of this study was to determine the amount of functional ED treatment capacity that was used to board inpatients during 12 months of operations at a community hospital and to estimate the value of that lost treatment capacity.

Methods: Historical data from 62,588 patient visits to the ED of a 450-bed nonprofit community teaching hospital in south central Pennsylvania between July 2004 and June 2005 were used to determine the amount of treatment bed occupancy lost to inpatient holding and the revenue potential of utilizing that blocked production capacity for additional patient visits.

Results: Transferring admitted patients from the ED to an inpatient unit within 120 minutes would have increased the functional treatment capacity of the ED by 10,397 hours during the 12 months of this study. By reducing admission process delays, the hospital could potentially have accommodated another 3,175 patient encounters in its existing treatment spaces. Providing emergency services to new patients in ED beds formerly used to board inpatients could have generated $3,960,264 in additional net revenue for the hospital.

Conclusions: Significantly higher operational revenues could be generated by reducing output delays that restrict optimal utilization of existing ED treatment capacity.

https://onlinelibrary.wiley.com/doi/pdf/10.1197/j.aem.2006.11.011

The Opportunity Loss of Boarding Admitted Patients in the Emergency Department

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Papers

The financial impact of ambulance diversions and patient elopements.

Time Value Stream Mapping As a Tool to Measure Patient Flow Through Emergency Department Triage

An evaluation of automated defibrillation and manual defibrillation by emergency medical technicians in a rural setting

The Opportunity Loss of Boarding Admitted Patients in the Emergency Department