5 Ways to Prevent Emergency Department Overcrowding

Emergency department overcrowding occurs anytime the patient demand exceeds the capacity to deliver care in a timely manner, congesting wait rooms and driving treatment delays that can prove fatal. It’s often more than just a matter of sudden, debilitating surges in patient volume — typically the result of stalled patient transfers leading to emergency department (ED) boarding scenarios that create access barriers for incoming (or new) patients.

Everyone recognizes that overcrowded hospitals are a significant concern. However, not everyone fully comprehends its complex, causative factors within the ED specifically, or the extent of its systemic impacts.

This guide explores those issues in addition to offering tips for preventing overcrowding from compromising your ED patient flow. Equipped with practical strategies for managing effective patient throughput, you’ll be better positioned to maximize operational efficiency while still providing the quality care that motivates patients to seek your emergency services.

What Causes ED Overcrowding?

Growing demand is driving increased episodes (and risk) of emergency room overcrowding. Statistics show a 40% hike in patient volume since 2020, contributing to fuller wait rooms across nationwide emergency centers. Some of the many reasons for this spike include:

• Systemwide access blocks that give patients no other outlet for care, such as restrictive business hours across primary (or urgent) care settings.
• Sicker, more complex patients due to increased prevalence of chronic conditions among a rapidly aging (and fragile) population.
• Frequent readmissions of geriatric and psychiatric patients, and patients with unspecified diagnoses.
• Extended lengths of patient stays that tie up necessary inpatient beds, prompting ER boarding scenarios that congest the space and delay throughput.
• Systemic staff shortages across healthcare settings, from the primary space to the acute care setting, restricting external access points and reducing capacity (by limiting the number of available staffed patient beds, for example).
• Medical surges that generate excessive demand, forecasted (like during cold and flu seasonal spikes) or unforeseen (due to a natural disaster, for example).

What Are the Systemwide Impacts of ED Overcrowding?

During the global pandemic, many assumed that the national emergency department overcrowding scale had reached a tipping point, but patient demand continued to expand in the following years. Projections forecast that if current trajectories continue, U.S. hospital occupancy will reach dangerous levels by 2032. These alarming forecasts amplify existing overcrowding issues, including those examined below.

Who Suffers the Most From ED Overcrowding?

Emergency department overcrowding affects organizational, staff, and patient outcomes. In years past, major hospitals in Texas, Florida, and Washington received the highest number of ED visits (respectively). Of those states, Washington has continued to suffer from emergency department occupancy rates that extend beyond safe capacity standards. However, these states are not alone in trying to manage high patient volumes. The problem is nationwide and presents additional concern for facilities that cater to vulnerable populations, such as:

• Rural and/or critical access hospitals.
• Stand-alone emergency departments.
• Facilities that cater to geriatric and medically fragile patient populations.

Preventing Emergency Department Overcrowding: Solutions and Tips

This issue isn’t a problem caused by (and to be solved by) ED teams alone. It’s a systemic failure that’s highlighted by ED overcrowding, much like the canary in the coal mine alerting trouble. Solutions therefore need to be pursued and applied by the system as a whole.

Customize these capacity management strategies (found below) to meet the needs of your organization as patient volumes grow, and consider implementing some of these tips for mitigating the risks associated with overcrowded hospitals.

1. Maximize Resource Utilization to Create More Patient Beds

Whether it’s designing a system for triaging patients and addressing their initial care needs from the waiting room, or a staffing plan that accounts for daily census fluctuations, resources need to target overcrowding. This means that space, staff, and supplies should be allocated toward this problem so that the ED has the means to effectively address overcrowding.

Suggestions:

• Use an alternative nursing care delivery model to tackle unexpected surges. For predicted surges, partner with a staffing company to avoid the risk of understaffing during high-volume events.
• Consider creating shared transfer or discharge lounges to free beds for patients who need emergency care.

2. Share Accountability for Patients Across the Hospital

An accountability framework that zones patients according to responsible services is critical to the success of ED throughput efficiency. Delays within the input, throughput, and output emergency department productivity model are often caused by stalled transfers and inpatient access barriers.

Therefore, hospital initiatives targeting ED patient flow metrics must place equal responsibility on assuming units for managing patients as soon as they’re referred to that service. This would make inpatient operational leaders responsible for patients as soon as they’re marked for in-house transfer from the ED.

Suggestions:

• Bring the ED’s throughput remediation data to stakeholder meetings to underscore that this issue (and accountability) is shared, and to avoid suggestions that this is merely an offloading tactic.
• Rope in nonclinical members and departments, such as environmental or custodial services to this shared accountability for better throughput via targeted training and education.

3. Utilize Nurse Initiated Order Protocols

Many admitting diagnoses are common, requiring similar therapeutic responses across patients (such as with heart attack rule outs). ED patient input, throughput, and output can be expedited — and physician workloads alleviated — through the implementation of MD-directed flowcharts, prompting the nurse-driven initiation of established order protocols. This helps streamline the management of patient presentations that nursing staff may be accustomed to caring for, while ensuring safety through doctor-designated parameters for protocol usage.

Suggestions:

• Implement a discharge order protocol, guided by a physician-designed flowchart that bases DC initiation on if, then process flow diagrams.
• Eradicate the use of routine orders within the ED (such as IV placement on every patient). It’s antithetical to the purpose of emergency medicine where nothing is routine and often creates unnecessary bottlenecks across patient care.

4. Leverage Technology to Improve ED Throughput

Using the latest technologies can help clinicians offload low-value tasks (such as data entry) to focus on patients and treatment priorities, while also offering opportunities for workflow assistance through automation. The possibilities for remote nursing monitoring and virtual appointments can also offset patient demand, and is worth pursuing via community engagement and intersystem partnerships with primary care services.

Suggestions:

• Create virtual emergency department options (or teams) to divert less critical patients while still providing them with necessary care.
• Use technology-assisted predictive modeling to help project and improve planning around medical surges.

5. Track and Review ED Key Performance Data

Gathering key performance indicators (like ED wait times) can help provide the necessary data to develop an evidence-backed strategy for managing emergency department overcrowding. Most electronic health record (EHR) systems offer integrated data tracking options, offsetting the organizational toll of data collection and allowing leaders to instead focus on analysis. Use those reports to guide targeted responses to overcrowding.

Suggestions:

• Consider offering Pay for Results incentives that reward (and encourage) optimal ED flow metrics.
• Inform bed turnover in overcapacity plans (or surge capacity directives) by triaging all patients across the hospital, so that the most stable, discharge-ready patients can be rapidly transferred or moved to accommodate patients with greater need.

Optimize Your KPI Usage to Boost Productivity

Emergency department overcrowding causes and solutions aren’t the only information bites necessary for effectively meeting growing patient demand. Make your clinical and operational data more meaningful through our facility guides and healthcare management insights, designed to help you overcome today’s most pressing challenges.