Research by Lee Ann Jarousse

A trip to the emergency department too often conjures up images of crowded waiting rooms and extensive wait times. And rightly so. Emergency departments in the United States continue to experience overcrowding, crippling their ability to handle day-to-day emergencies much less natural disasters or acts of terrorism. "Emergency department usage continues to increase year after year, outpacing population growth for the past 15 years," says Jesse Pines, M.D., director of the Center for Health Care Quality at the George Washington University Medical Center, Washington, D.C. During the same time period, the number of EDs has declined, creating the classic scenario of lower supply and greater demand.

The implications could not be more serious, creating a significant quality and safety issue for the ED. Delays in treatment can result in patient harm, including death. Long wait times negatively impact patient and employee satisfaction and also increase the likelihood of patients leaving without being seen. Overcrowding increases health care costs through longer lengths of stay and increased negligence claims, among other things.

The good news is there are proven solutions to reduce ED overcrowding, many of which are inexpensive. Building a new, state-of-the-art ED, for example, is not always the answer nor is employing more clinicians to care for patients.

Fixing the ED is not a simple task, however. "What works in one hospital may not work in another," says AnnMarie Papa, R.N., clinical nurse specialist at the Hospital of the University of Pennsylvania, Philadelphia, and president of the Emergency Nurses Association. It requires hospitalwide involvement to include ED clinicians, inpatient care representatives, housekeeping, radiology, pharmacy and hospital leadership, among others. "To make good, sustainable, systemwide changes takes three to seven years," Papa adds.

A good place to start is with an assessment of the input/throughput/output of ED patients to identify the gaps in the system that lead to overcrowding. The results will pinpoint where the organization can focus its resources to optimize results. "The key is learning how to manage hospital capacity as a whole," says Jeff Terry, managing principle of clinical operations for GE Healthcare Performance Solutions. "If you can change capacity at the enterprise level, that will trickle down to the ED."

Factors contributing to emergency department overcrowding


  • Limited access to primary care
  • A growing elderly population
  • Inadequate access to inpatient and outpatient mental health services
  • High rates of uninsured and underinsured
  • ED closures


  • Lack of access to on-call specialists
  • Variation in surgical schedules with more elective procedures scheduled for earlier in the week
  • ED boarding
  • Inefficient discharge and bed-turnover process
  • Inefficient registration process

Source: H&HN research, 2011

The emergency department input >>throughput >> output model

Emergency departments in the United States continue to experience overcrowding, hindering access to care. EDs are unique, in part, because their operations are dependent on such external factors as patient demand and internal factors like availability of inpatient beds. To that end, addressing overcrowding is not an ED issue; it's a systemwide issue. Take a look at the three factors that contribute to ED crowding — input, throughout and output — as well as some potential solutions. To be successful, hospitals need to identify problems and address opportunities for improvement in all three areas.


Input refers to the flow of patients to the emergency department and is one of the most difficult aspects to control. Input can vary significantly between regions and even within health systems. Patient demographics, including insurance status and age of the population, and access to primary care, are among the factors contributing to ED demand. The availability of alternative sites of care within the community is another important factor. If an ED closes, it increases the burden for the remaining EDs within the community.

Potential solutions

  • Provide after-hours clinic care.
  • Establish a nurse hotline to address patients' health concerns to avoid ED visits for nonemergent needs.
  • Enhance post-discharge follow-up procedures with certain patient populations to avoid unnecessary readmissions.


Throughput refers to emergency department processes that impact patient flow. This includes triage, staffing, availability of specialty and diagnostic services, surgical scheduling and information technology resources. Disruptions in any one of these, and other areas, can create a backlog within the ED resulting in long wait times and increase the likelihood of patients leaving before being seen by a physician or another practitioner.

Potential solutions

  • Provide physician triage in the ED.
  • Build a point-of-care testing satellite laboratory.
  • Establish a fast-track system that allows nonurgent patients to be treated faster by providers other than physicians.
  • Establish an observation unit to move patients in need of short hospitalization.
  • Offer preferred operating room times to specialists for on-call coverage.


Output refers to the ability of the emergency department to discharge patients either for inpatient admission or for follow-up care in the community. Lack of inpatient beds is a primary cause for boarding — the practice of keeping admitted patients in the ED until an inpatient bed is made available. This causes considerable backup because admitted patients use beds and resources needed to treat incoming emergency patients.

Potential solutions

  • Move patients from the ED immediately after admission.
  • Optimize operating room scheduling.
  • Hire a bed czar to oversee the timely, appropriate transfer of ED patients to inpatient areas.
  • Create a discharge lounge for patients who are ready for discharge, but are waiting for medications, transportation or education.
  • Coordinate the discharge of inpatients before noon.
  • Create an intermediate ICU to increase ICU capacity.

No Space, No Problem

Rapid population growth in the Phoenix area placed tremendous stress on emergency departments that had not kept pace with the change. For Banner Health, a 23-hospital system with locations in seven states, long wait times increasingly were becoming a problem at its Phoenix-area facilities. The number of patients choosing to leave without being seen by a doctor grew to 13 percent at some facilities. "The pain they were experiencing in the waiting room was worse than the pain that brought them there in the first place," says Twila Burdick, Banner Health's vice president for organizational performance. In 2002, the system turned to industrial engineers from Arizona State University to study the science of throughput and determine how it can be applied to health care. The resulting Door-to-Doc program reduced the average wait time to see a physician by 58 percent and the percentage of patients who left without treatment improved by 76 percent.

"We recognized that not all ED patients are sick enough to require beds the entire time they are there," Burdick says. A split-flow model places sicker patients (those more likely to be hospitalized) into beds, while less-sick patients remain dressed and ambulatory whenever possible. Among the changes: less-sick patients walk to testing locations and exam rooms, instead of waiting for transport. "We move less-sick patients through the system a lot faster," says Burdick. "It's emptied out our waiting rooms and we are able to see more patients within the same space and the same bed count." Banner received a grant from the Agency for Healthcare Research and Quality to produce a Door-to-Doc implementation toolkit. For more information, visit: