The Effect of Emergency Department Crowding on Clinically Oriented Outcomes

Authors

  • Steven L. Bernstein MD,

    1. From the Department of Emergency Medicine, Albert Einstein College of Medicine (SLB), Bronx, NY; the Department of Emergency Medicine, Vanderbilt University (DA), Nashville, TN; the Department of Emergency Medicine, University of Pennsylvania (RD, JMP), Philadelphia, PA; the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (SE), Boston, MA; the Department of Emergency Medicine, Oregon Health & Science University (DH, KJM), Portland, OR; the Department of Emergency Medicine, Mount Sinai Medical Center (UH), New York, NY; the Department of Emergency Medicine, Johns Hopkins University (MM), Baltimore, MD; the Department of Emergency Medicine, Boston University (NR), Boston, MA; the Department of Emergency Medicine, Carolinas Medical Center (RS), Charlotte, NC; the Department of Emergency Medicine, University of Rochester (FZ), Rochester, NY; the Department of Emergency Medicine, Sunnybrook & Women’s College Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Regions Hospital (BRA), St. Paul, MN.
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  • Dominik Aronsky MD,

    1. From the Department of Emergency Medicine, Albert Einstein College of Medicine (SLB), Bronx, NY; the Department of Emergency Medicine, Vanderbilt University (DA), Nashville, TN; the Department of Emergency Medicine, University of Pennsylvania (RD, JMP), Philadelphia, PA; the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (SE), Boston, MA; the Department of Emergency Medicine, Oregon Health & Science University (DH, KJM), Portland, OR; the Department of Emergency Medicine, Mount Sinai Medical Center (UH), New York, NY; the Department of Emergency Medicine, Johns Hopkins University (MM), Baltimore, MD; the Department of Emergency Medicine, Boston University (NR), Boston, MA; the Department of Emergency Medicine, Carolinas Medical Center (RS), Charlotte, NC; the Department of Emergency Medicine, University of Rochester (FZ), Rochester, NY; the Department of Emergency Medicine, Sunnybrook & Women’s College Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Regions Hospital (BRA), St. Paul, MN.
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  • Reena Duseja MD,

    1. From the Department of Emergency Medicine, Albert Einstein College of Medicine (SLB), Bronx, NY; the Department of Emergency Medicine, Vanderbilt University (DA), Nashville, TN; the Department of Emergency Medicine, University of Pennsylvania (RD, JMP), Philadelphia, PA; the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (SE), Boston, MA; the Department of Emergency Medicine, Oregon Health & Science University (DH, KJM), Portland, OR; the Department of Emergency Medicine, Mount Sinai Medical Center (UH), New York, NY; the Department of Emergency Medicine, Johns Hopkins University (MM), Baltimore, MD; the Department of Emergency Medicine, Boston University (NR), Boston, MA; the Department of Emergency Medicine, Carolinas Medical Center (RS), Charlotte, NC; the Department of Emergency Medicine, University of Rochester (FZ), Rochester, NY; the Department of Emergency Medicine, Sunnybrook & Women’s College Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Regions Hospital (BRA), St. Paul, MN.
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  • Stephen Epstein MD,

    1. From the Department of Emergency Medicine, Albert Einstein College of Medicine (SLB), Bronx, NY; the Department of Emergency Medicine, Vanderbilt University (DA), Nashville, TN; the Department of Emergency Medicine, University of Pennsylvania (RD, JMP), Philadelphia, PA; the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (SE), Boston, MA; the Department of Emergency Medicine, Oregon Health & Science University (DH, KJM), Portland, OR; the Department of Emergency Medicine, Mount Sinai Medical Center (UH), New York, NY; the Department of Emergency Medicine, Johns Hopkins University (MM), Baltimore, MD; the Department of Emergency Medicine, Boston University (NR), Boston, MA; the Department of Emergency Medicine, Carolinas Medical Center (RS), Charlotte, NC; the Department of Emergency Medicine, University of Rochester (FZ), Rochester, NY; the Department of Emergency Medicine, Sunnybrook & Women’s College Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Regions Hospital (BRA), St. Paul, MN.
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  • Dan Handel MD, MPH,

    1. From the Department of Emergency Medicine, Albert Einstein College of Medicine (SLB), Bronx, NY; the Department of Emergency Medicine, Vanderbilt University (DA), Nashville, TN; the Department of Emergency Medicine, University of Pennsylvania (RD, JMP), Philadelphia, PA; the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (SE), Boston, MA; the Department of Emergency Medicine, Oregon Health & Science University (DH, KJM), Portland, OR; the Department of Emergency Medicine, Mount Sinai Medical Center (UH), New York, NY; the Department of Emergency Medicine, Johns Hopkins University (MM), Baltimore, MD; the Department of Emergency Medicine, Boston University (NR), Boston, MA; the Department of Emergency Medicine, Carolinas Medical Center (RS), Charlotte, NC; the Department of Emergency Medicine, University of Rochester (FZ), Rochester, NY; the Department of Emergency Medicine, Sunnybrook & Women’s College Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Regions Hospital (BRA), St. Paul, MN.
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  • Ula Hwang MD, MPH,

    1. From the Department of Emergency Medicine, Albert Einstein College of Medicine (SLB), Bronx, NY; the Department of Emergency Medicine, Vanderbilt University (DA), Nashville, TN; the Department of Emergency Medicine, University of Pennsylvania (RD, JMP), Philadelphia, PA; the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (SE), Boston, MA; the Department of Emergency Medicine, Oregon Health & Science University (DH, KJM), Portland, OR; the Department of Emergency Medicine, Mount Sinai Medical Center (UH), New York, NY; the Department of Emergency Medicine, Johns Hopkins University (MM), Baltimore, MD; the Department of Emergency Medicine, Boston University (NR), Boston, MA; the Department of Emergency Medicine, Carolinas Medical Center (RS), Charlotte, NC; the Department of Emergency Medicine, University of Rochester (FZ), Rochester, NY; the Department of Emergency Medicine, Sunnybrook & Women’s College Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Regions Hospital (BRA), St. Paul, MN.
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  • Melissa McCarthy ScD,

    1. From the Department of Emergency Medicine, Albert Einstein College of Medicine (SLB), Bronx, NY; the Department of Emergency Medicine, Vanderbilt University (DA), Nashville, TN; the Department of Emergency Medicine, University of Pennsylvania (RD, JMP), Philadelphia, PA; the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (SE), Boston, MA; the Department of Emergency Medicine, Oregon Health & Science University (DH, KJM), Portland, OR; the Department of Emergency Medicine, Mount Sinai Medical Center (UH), New York, NY; the Department of Emergency Medicine, Johns Hopkins University (MM), Baltimore, MD; the Department of Emergency Medicine, Boston University (NR), Boston, MA; the Department of Emergency Medicine, Carolinas Medical Center (RS), Charlotte, NC; the Department of Emergency Medicine, University of Rochester (FZ), Rochester, NY; the Department of Emergency Medicine, Sunnybrook & Women’s College Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Regions Hospital (BRA), St. Paul, MN.
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  • K. John McConnell PhD,

    1. From the Department of Emergency Medicine, Albert Einstein College of Medicine (SLB), Bronx, NY; the Department of Emergency Medicine, Vanderbilt University (DA), Nashville, TN; the Department of Emergency Medicine, University of Pennsylvania (RD, JMP), Philadelphia, PA; the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (SE), Boston, MA; the Department of Emergency Medicine, Oregon Health & Science University (DH, KJM), Portland, OR; the Department of Emergency Medicine, Mount Sinai Medical Center (UH), New York, NY; the Department of Emergency Medicine, Johns Hopkins University (MM), Baltimore, MD; the Department of Emergency Medicine, Boston University (NR), Boston, MA; the Department of Emergency Medicine, Carolinas Medical Center (RS), Charlotte, NC; the Department of Emergency Medicine, University of Rochester (FZ), Rochester, NY; the Department of Emergency Medicine, Sunnybrook & Women’s College Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Regions Hospital (BRA), St. Paul, MN.
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  • Jesse M. Pines MD, MBA, MSCE,

    1. From the Department of Emergency Medicine, Albert Einstein College of Medicine (SLB), Bronx, NY; the Department of Emergency Medicine, Vanderbilt University (DA), Nashville, TN; the Department of Emergency Medicine, University of Pennsylvania (RD, JMP), Philadelphia, PA; the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (SE), Boston, MA; the Department of Emergency Medicine, Oregon Health & Science University (DH, KJM), Portland, OR; the Department of Emergency Medicine, Mount Sinai Medical Center (UH), New York, NY; the Department of Emergency Medicine, Johns Hopkins University (MM), Baltimore, MD; the Department of Emergency Medicine, Boston University (NR), Boston, MA; the Department of Emergency Medicine, Carolinas Medical Center (RS), Charlotte, NC; the Department of Emergency Medicine, University of Rochester (FZ), Rochester, NY; the Department of Emergency Medicine, Sunnybrook & Women’s College Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Regions Hospital (BRA), St. Paul, MN.
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  • Niels Rathlev MD,

    1. From the Department of Emergency Medicine, Albert Einstein College of Medicine (SLB), Bronx, NY; the Department of Emergency Medicine, Vanderbilt University (DA), Nashville, TN; the Department of Emergency Medicine, University of Pennsylvania (RD, JMP), Philadelphia, PA; the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (SE), Boston, MA; the Department of Emergency Medicine, Oregon Health & Science University (DH, KJM), Portland, OR; the Department of Emergency Medicine, Mount Sinai Medical Center (UH), New York, NY; the Department of Emergency Medicine, Johns Hopkins University (MM), Baltimore, MD; the Department of Emergency Medicine, Boston University (NR), Boston, MA; the Department of Emergency Medicine, Carolinas Medical Center (RS), Charlotte, NC; the Department of Emergency Medicine, University of Rochester (FZ), Rochester, NY; the Department of Emergency Medicine, Sunnybrook & Women’s College Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Regions Hospital (BRA), St. Paul, MN.
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  • Robert Schafermeyer MD,

    1. From the Department of Emergency Medicine, Albert Einstein College of Medicine (SLB), Bronx, NY; the Department of Emergency Medicine, Vanderbilt University (DA), Nashville, TN; the Department of Emergency Medicine, University of Pennsylvania (RD, JMP), Philadelphia, PA; the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (SE), Boston, MA; the Department of Emergency Medicine, Oregon Health & Science University (DH, KJM), Portland, OR; the Department of Emergency Medicine, Mount Sinai Medical Center (UH), New York, NY; the Department of Emergency Medicine, Johns Hopkins University (MM), Baltimore, MD; the Department of Emergency Medicine, Boston University (NR), Boston, MA; the Department of Emergency Medicine, Carolinas Medical Center (RS), Charlotte, NC; the Department of Emergency Medicine, University of Rochester (FZ), Rochester, NY; the Department of Emergency Medicine, Sunnybrook & Women’s College Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Regions Hospital (BRA), St. Paul, MN.
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  • Frank Zwemer MD,

    1. From the Department of Emergency Medicine, Albert Einstein College of Medicine (SLB), Bronx, NY; the Department of Emergency Medicine, Vanderbilt University (DA), Nashville, TN; the Department of Emergency Medicine, University of Pennsylvania (RD, JMP), Philadelphia, PA; the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (SE), Boston, MA; the Department of Emergency Medicine, Oregon Health & Science University (DH, KJM), Portland, OR; the Department of Emergency Medicine, Mount Sinai Medical Center (UH), New York, NY; the Department of Emergency Medicine, Johns Hopkins University (MM), Baltimore, MD; the Department of Emergency Medicine, Boston University (NR), Boston, MA; the Department of Emergency Medicine, Carolinas Medical Center (RS), Charlotte, NC; the Department of Emergency Medicine, University of Rochester (FZ), Rochester, NY; the Department of Emergency Medicine, Sunnybrook & Women’s College Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Regions Hospital (BRA), St. Paul, MN.
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  • Michael Schull MD,

    1. From the Department of Emergency Medicine, Albert Einstein College of Medicine (SLB), Bronx, NY; the Department of Emergency Medicine, Vanderbilt University (DA), Nashville, TN; the Department of Emergency Medicine, University of Pennsylvania (RD, JMP), Philadelphia, PA; the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (SE), Boston, MA; the Department of Emergency Medicine, Oregon Health & Science University (DH, KJM), Portland, OR; the Department of Emergency Medicine, Mount Sinai Medical Center (UH), New York, NY; the Department of Emergency Medicine, Johns Hopkins University (MM), Baltimore, MD; the Department of Emergency Medicine, Boston University (NR), Boston, MA; the Department of Emergency Medicine, Carolinas Medical Center (RS), Charlotte, NC; the Department of Emergency Medicine, University of Rochester (FZ), Rochester, NY; the Department of Emergency Medicine, Sunnybrook & Women’s College Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Regions Hospital (BRA), St. Paul, MN.
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  • Brent R. Asplin MD, MPH,

    1. From the Department of Emergency Medicine, Albert Einstein College of Medicine (SLB), Bronx, NY; the Department of Emergency Medicine, Vanderbilt University (DA), Nashville, TN; the Department of Emergency Medicine, University of Pennsylvania (RD, JMP), Philadelphia, PA; the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (SE), Boston, MA; the Department of Emergency Medicine, Oregon Health & Science University (DH, KJM), Portland, OR; the Department of Emergency Medicine, Mount Sinai Medical Center (UH), New York, NY; the Department of Emergency Medicine, Johns Hopkins University (MM), Baltimore, MD; the Department of Emergency Medicine, Boston University (NR), Boston, MA; the Department of Emergency Medicine, Carolinas Medical Center (RS), Charlotte, NC; the Department of Emergency Medicine, University of Rochester (FZ), Rochester, NY; the Department of Emergency Medicine, Sunnybrook & Women’s College Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Regions Hospital (BRA), St. Paul, MN.
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  • Society for Academic Emergency Medicine, Emergency Department Crowding Task Force

    1. From the Department of Emergency Medicine, Albert Einstein College of Medicine (SLB), Bronx, NY; the Department of Emergency Medicine, Vanderbilt University (DA), Nashville, TN; the Department of Emergency Medicine, University of Pennsylvania (RD, JMP), Philadelphia, PA; the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (SE), Boston, MA; the Department of Emergency Medicine, Oregon Health & Science University (DH, KJM), Portland, OR; the Department of Emergency Medicine, Mount Sinai Medical Center (UH), New York, NY; the Department of Emergency Medicine, Johns Hopkins University (MM), Baltimore, MD; the Department of Emergency Medicine, Boston University (NR), Boston, MA; the Department of Emergency Medicine, Carolinas Medical Center (RS), Charlotte, NC; the Department of Emergency Medicine, University of Rochester (FZ), Rochester, NY; the Department of Emergency Medicine, Sunnybrook & Women’s College Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Regions Hospital (BRA), St. Paul, MN.
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  • Presented at the Society for Academic Emergency Medicine (SAEM) Annual Meeting, Washington, DC, May 30, 2008.

  • Approved by the SAEM Board of Directors, July 9, 2008.

Address for correspondence and reprints: Steven L. Bernstein, MD; e-mail: sbernste@montefiore.org.

Abstract

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.

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