International Perspectives on Emergency Department Crowding

Authors

  • Jesse M. Pines MD, MBA, MSCE,

    1. From the Center for Health Care Quality and an Emergency Medicine and Health Policy, George Washington University (JMP), Washington, DC; the Department of Emergency Medicine, Hospital of the University of Pennsylvania (JAH), Philadelphia, PA; the Department of Emergency Medicine, University of California, San Francisco (EJW), San Francisco, CA; the Emergency Department, Langeland Hospital (AJA), Zoetermeer, the Netherlands; Pediatric Emergency Medicine, King Faisal Specialist Hospital & Research Center (HAS), Riyadh, Saudi Arabia; International Emergency Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (PDA), Boston, MA; Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (MB); Emergency Medicine Ward and Observation Unit in Pisa Hospital (Italy) and Emergency Medicine, Tuscany Emergency Medicine Project in Collaboration With Harvard International (AB), Pisa, Italy; Anesthesiology and Emergency Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (AG); Catalan Health Service and at the EMS, Hospital Accreditation Service at Catalan Health Service, Catalan EMS, Catalan Emergency Integral Plan (SF), Catalonia; the Division of Emergency Care at Helsinki University Central Hospital (VPH), Helsinki, Finland; the Emergency Department at the Asklepios Hospital Hamburg-Altona (BH), Hamburg, Germany; Emergency Medicine, Olean General Hospital (VAK), Olean, NY; Emergency Medicine and Health Services Research, University of Sheffield (SM), Sheffield, UK; the Department of Emergency Medicine, Karolinska University Hospital (GO), Stockholm, Sweden; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong (TR), Hong Kong; the Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center (NKR), Springfield, MA; Prehospital and Emergency Medicine, Hospital of Victor Jousselin’s Hospital (ER), Dreux, France; NRMA-ACT, Australian National University Medical School, Emergency Medicine, The Canberra Hospital (DBR), Canberra, Australia; the Department of Emergency Medicine, George Washington University (MS [Iran]), Washington, DC; the Division of Emergency Medicine (Department of Medicine), University of Toronto, Institute for Clinical Evaluative Sciences, Emergency Medicine, Sunnybrook Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Harvard Medical School (BM), Boston, MA.
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  • Joshua A. Hilton MD,

    1. From the Center for Health Care Quality and an Emergency Medicine and Health Policy, George Washington University (JMP), Washington, DC; the Department of Emergency Medicine, Hospital of the University of Pennsylvania (JAH), Philadelphia, PA; the Department of Emergency Medicine, University of California, San Francisco (EJW), San Francisco, CA; the Emergency Department, Langeland Hospital (AJA), Zoetermeer, the Netherlands; Pediatric Emergency Medicine, King Faisal Specialist Hospital & Research Center (HAS), Riyadh, Saudi Arabia; International Emergency Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (PDA), Boston, MA; Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (MB); Emergency Medicine Ward and Observation Unit in Pisa Hospital (Italy) and Emergency Medicine, Tuscany Emergency Medicine Project in Collaboration With Harvard International (AB), Pisa, Italy; Anesthesiology and Emergency Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (AG); Catalan Health Service and at the EMS, Hospital Accreditation Service at Catalan Health Service, Catalan EMS, Catalan Emergency Integral Plan (SF), Catalonia; the Division of Emergency Care at Helsinki University Central Hospital (VPH), Helsinki, Finland; the Emergency Department at the Asklepios Hospital Hamburg-Altona (BH), Hamburg, Germany; Emergency Medicine, Olean General Hospital (VAK), Olean, NY; Emergency Medicine and Health Services Research, University of Sheffield (SM), Sheffield, UK; the Department of Emergency Medicine, Karolinska University Hospital (GO), Stockholm, Sweden; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong (TR), Hong Kong; the Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center (NKR), Springfield, MA; Prehospital and Emergency Medicine, Hospital of Victor Jousselin’s Hospital (ER), Dreux, France; NRMA-ACT, Australian National University Medical School, Emergency Medicine, The Canberra Hospital (DBR), Canberra, Australia; the Department of Emergency Medicine, George Washington University (MS [Iran]), Washington, DC; the Division of Emergency Medicine (Department of Medicine), University of Toronto, Institute for Clinical Evaluative Sciences, Emergency Medicine, Sunnybrook Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Harvard Medical School (BM), Boston, MA.
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  • Ellen J. Weber MD,

    1. From the Center for Health Care Quality and an Emergency Medicine and Health Policy, George Washington University (JMP), Washington, DC; the Department of Emergency Medicine, Hospital of the University of Pennsylvania (JAH), Philadelphia, PA; the Department of Emergency Medicine, University of California, San Francisco (EJW), San Francisco, CA; the Emergency Department, Langeland Hospital (AJA), Zoetermeer, the Netherlands; Pediatric Emergency Medicine, King Faisal Specialist Hospital & Research Center (HAS), Riyadh, Saudi Arabia; International Emergency Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (PDA), Boston, MA; Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (MB); Emergency Medicine Ward and Observation Unit in Pisa Hospital (Italy) and Emergency Medicine, Tuscany Emergency Medicine Project in Collaboration With Harvard International (AB), Pisa, Italy; Anesthesiology and Emergency Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (AG); Catalan Health Service and at the EMS, Hospital Accreditation Service at Catalan Health Service, Catalan EMS, Catalan Emergency Integral Plan (SF), Catalonia; the Division of Emergency Care at Helsinki University Central Hospital (VPH), Helsinki, Finland; the Emergency Department at the Asklepios Hospital Hamburg-Altona (BH), Hamburg, Germany; Emergency Medicine, Olean General Hospital (VAK), Olean, NY; Emergency Medicine and Health Services Research, University of Sheffield (SM), Sheffield, UK; the Department of Emergency Medicine, Karolinska University Hospital (GO), Stockholm, Sweden; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong (TR), Hong Kong; the Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center (NKR), Springfield, MA; Prehospital and Emergency Medicine, Hospital of Victor Jousselin’s Hospital (ER), Dreux, France; NRMA-ACT, Australian National University Medical School, Emergency Medicine, The Canberra Hospital (DBR), Canberra, Australia; the Department of Emergency Medicine, George Washington University (MS [Iran]), Washington, DC; the Division of Emergency Medicine (Department of Medicine), University of Toronto, Institute for Clinical Evaluative Sciences, Emergency Medicine, Sunnybrook Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Harvard Medical School (BM), Boston, MA.
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  • Annechien J. Alkemade MD,

    1. From the Center for Health Care Quality and an Emergency Medicine and Health Policy, George Washington University (JMP), Washington, DC; the Department of Emergency Medicine, Hospital of the University of Pennsylvania (JAH), Philadelphia, PA; the Department of Emergency Medicine, University of California, San Francisco (EJW), San Francisco, CA; the Emergency Department, Langeland Hospital (AJA), Zoetermeer, the Netherlands; Pediatric Emergency Medicine, King Faisal Specialist Hospital & Research Center (HAS), Riyadh, Saudi Arabia; International Emergency Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (PDA), Boston, MA; Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (MB); Emergency Medicine Ward and Observation Unit in Pisa Hospital (Italy) and Emergency Medicine, Tuscany Emergency Medicine Project in Collaboration With Harvard International (AB), Pisa, Italy; Anesthesiology and Emergency Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (AG); Catalan Health Service and at the EMS, Hospital Accreditation Service at Catalan Health Service, Catalan EMS, Catalan Emergency Integral Plan (SF), Catalonia; the Division of Emergency Care at Helsinki University Central Hospital (VPH), Helsinki, Finland; the Emergency Department at the Asklepios Hospital Hamburg-Altona (BH), Hamburg, Germany; Emergency Medicine, Olean General Hospital (VAK), Olean, NY; Emergency Medicine and Health Services Research, University of Sheffield (SM), Sheffield, UK; the Department of Emergency Medicine, Karolinska University Hospital (GO), Stockholm, Sweden; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong (TR), Hong Kong; the Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center (NKR), Springfield, MA; Prehospital and Emergency Medicine, Hospital of Victor Jousselin’s Hospital (ER), Dreux, France; NRMA-ACT, Australian National University Medical School, Emergency Medicine, The Canberra Hospital (DBR), Canberra, Australia; the Department of Emergency Medicine, George Washington University (MS [Iran]), Washington, DC; the Division of Emergency Medicine (Department of Medicine), University of Toronto, Institute for Clinical Evaluative Sciences, Emergency Medicine, Sunnybrook Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Harvard Medical School (BM), Boston, MA.
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  • Hasan Al Shabanah MD,

    1. From the Center for Health Care Quality and an Emergency Medicine and Health Policy, George Washington University (JMP), Washington, DC; the Department of Emergency Medicine, Hospital of the University of Pennsylvania (JAH), Philadelphia, PA; the Department of Emergency Medicine, University of California, San Francisco (EJW), San Francisco, CA; the Emergency Department, Langeland Hospital (AJA), Zoetermeer, the Netherlands; Pediatric Emergency Medicine, King Faisal Specialist Hospital & Research Center (HAS), Riyadh, Saudi Arabia; International Emergency Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (PDA), Boston, MA; Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (MB); Emergency Medicine Ward and Observation Unit in Pisa Hospital (Italy) and Emergency Medicine, Tuscany Emergency Medicine Project in Collaboration With Harvard International (AB), Pisa, Italy; Anesthesiology and Emergency Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (AG); Catalan Health Service and at the EMS, Hospital Accreditation Service at Catalan Health Service, Catalan EMS, Catalan Emergency Integral Plan (SF), Catalonia; the Division of Emergency Care at Helsinki University Central Hospital (VPH), Helsinki, Finland; the Emergency Department at the Asklepios Hospital Hamburg-Altona (BH), Hamburg, Germany; Emergency Medicine, Olean General Hospital (VAK), Olean, NY; Emergency Medicine and Health Services Research, University of Sheffield (SM), Sheffield, UK; the Department of Emergency Medicine, Karolinska University Hospital (GO), Stockholm, Sweden; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong (TR), Hong Kong; the Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center (NKR), Springfield, MA; Prehospital and Emergency Medicine, Hospital of Victor Jousselin’s Hospital (ER), Dreux, France; NRMA-ACT, Australian National University Medical School, Emergency Medicine, The Canberra Hospital (DBR), Canberra, Australia; the Department of Emergency Medicine, George Washington University (MS [Iran]), Washington, DC; the Division of Emergency Medicine (Department of Medicine), University of Toronto, Institute for Clinical Evaluative Sciences, Emergency Medicine, Sunnybrook Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Harvard Medical School (BM), Boston, MA.
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  • Philip D. Anderson MD,

    1. From the Center for Health Care Quality and an Emergency Medicine and Health Policy, George Washington University (JMP), Washington, DC; the Department of Emergency Medicine, Hospital of the University of Pennsylvania (JAH), Philadelphia, PA; the Department of Emergency Medicine, University of California, San Francisco (EJW), San Francisco, CA; the Emergency Department, Langeland Hospital (AJA), Zoetermeer, the Netherlands; Pediatric Emergency Medicine, King Faisal Specialist Hospital & Research Center (HAS), Riyadh, Saudi Arabia; International Emergency Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (PDA), Boston, MA; Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (MB); Emergency Medicine Ward and Observation Unit in Pisa Hospital (Italy) and Emergency Medicine, Tuscany Emergency Medicine Project in Collaboration With Harvard International (AB), Pisa, Italy; Anesthesiology and Emergency Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (AG); Catalan Health Service and at the EMS, Hospital Accreditation Service at Catalan Health Service, Catalan EMS, Catalan Emergency Integral Plan (SF), Catalonia; the Division of Emergency Care at Helsinki University Central Hospital (VPH), Helsinki, Finland; the Emergency Department at the Asklepios Hospital Hamburg-Altona (BH), Hamburg, Germany; Emergency Medicine, Olean General Hospital (VAK), Olean, NY; Emergency Medicine and Health Services Research, University of Sheffield (SM), Sheffield, UK; the Department of Emergency Medicine, Karolinska University Hospital (GO), Stockholm, Sweden; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong (TR), Hong Kong; the Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center (NKR), Springfield, MA; Prehospital and Emergency Medicine, Hospital of Victor Jousselin’s Hospital (ER), Dreux, France; NRMA-ACT, Australian National University Medical School, Emergency Medicine, The Canberra Hospital (DBR), Canberra, Australia; the Department of Emergency Medicine, George Washington University (MS [Iran]), Washington, DC; the Division of Emergency Medicine (Department of Medicine), University of Toronto, Institute for Clinical Evaluative Sciences, Emergency Medicine, Sunnybrook Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Harvard Medical School (BM), Boston, MA.
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  • Michael Bernhard MD,

    1. From the Center for Health Care Quality and an Emergency Medicine and Health Policy, George Washington University (JMP), Washington, DC; the Department of Emergency Medicine, Hospital of the University of Pennsylvania (JAH), Philadelphia, PA; the Department of Emergency Medicine, University of California, San Francisco (EJW), San Francisco, CA; the Emergency Department, Langeland Hospital (AJA), Zoetermeer, the Netherlands; Pediatric Emergency Medicine, King Faisal Specialist Hospital & Research Center (HAS), Riyadh, Saudi Arabia; International Emergency Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (PDA), Boston, MA; Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (MB); Emergency Medicine Ward and Observation Unit in Pisa Hospital (Italy) and Emergency Medicine, Tuscany Emergency Medicine Project in Collaboration With Harvard International (AB), Pisa, Italy; Anesthesiology and Emergency Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (AG); Catalan Health Service and at the EMS, Hospital Accreditation Service at Catalan Health Service, Catalan EMS, Catalan Emergency Integral Plan (SF), Catalonia; the Division of Emergency Care at Helsinki University Central Hospital (VPH), Helsinki, Finland; the Emergency Department at the Asklepios Hospital Hamburg-Altona (BH), Hamburg, Germany; Emergency Medicine, Olean General Hospital (VAK), Olean, NY; Emergency Medicine and Health Services Research, University of Sheffield (SM), Sheffield, UK; the Department of Emergency Medicine, Karolinska University Hospital (GO), Stockholm, Sweden; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong (TR), Hong Kong; the Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center (NKR), Springfield, MA; Prehospital and Emergency Medicine, Hospital of Victor Jousselin’s Hospital (ER), Dreux, France; NRMA-ACT, Australian National University Medical School, Emergency Medicine, The Canberra Hospital (DBR), Canberra, Australia; the Department of Emergency Medicine, George Washington University (MS [Iran]), Washington, DC; the Division of Emergency Medicine (Department of Medicine), University of Toronto, Institute for Clinical Evaluative Sciences, Emergency Medicine, Sunnybrook Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Harvard Medical School (BM), Boston, MA.
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  • Alessio Bertini MD,

    1. From the Center for Health Care Quality and an Emergency Medicine and Health Policy, George Washington University (JMP), Washington, DC; the Department of Emergency Medicine, Hospital of the University of Pennsylvania (JAH), Philadelphia, PA; the Department of Emergency Medicine, University of California, San Francisco (EJW), San Francisco, CA; the Emergency Department, Langeland Hospital (AJA), Zoetermeer, the Netherlands; Pediatric Emergency Medicine, King Faisal Specialist Hospital & Research Center (HAS), Riyadh, Saudi Arabia; International Emergency Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (PDA), Boston, MA; Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (MB); Emergency Medicine Ward and Observation Unit in Pisa Hospital (Italy) and Emergency Medicine, Tuscany Emergency Medicine Project in Collaboration With Harvard International (AB), Pisa, Italy; Anesthesiology and Emergency Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (AG); Catalan Health Service and at the EMS, Hospital Accreditation Service at Catalan Health Service, Catalan EMS, Catalan Emergency Integral Plan (SF), Catalonia; the Division of Emergency Care at Helsinki University Central Hospital (VPH), Helsinki, Finland; the Emergency Department at the Asklepios Hospital Hamburg-Altona (BH), Hamburg, Germany; Emergency Medicine, Olean General Hospital (VAK), Olean, NY; Emergency Medicine and Health Services Research, University of Sheffield (SM), Sheffield, UK; the Department of Emergency Medicine, Karolinska University Hospital (GO), Stockholm, Sweden; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong (TR), Hong Kong; the Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center (NKR), Springfield, MA; Prehospital and Emergency Medicine, Hospital of Victor Jousselin’s Hospital (ER), Dreux, France; NRMA-ACT, Australian National University Medical School, Emergency Medicine, The Canberra Hospital (DBR), Canberra, Australia; the Department of Emergency Medicine, George Washington University (MS [Iran]), Washington, DC; the Division of Emergency Medicine (Department of Medicine), University of Toronto, Institute for Clinical Evaluative Sciences, Emergency Medicine, Sunnybrook Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Harvard Medical School (BM), Boston, MA.
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  • André Gries MD,

    1. From the Center for Health Care Quality and an Emergency Medicine and Health Policy, George Washington University (JMP), Washington, DC; the Department of Emergency Medicine, Hospital of the University of Pennsylvania (JAH), Philadelphia, PA; the Department of Emergency Medicine, University of California, San Francisco (EJW), San Francisco, CA; the Emergency Department, Langeland Hospital (AJA), Zoetermeer, the Netherlands; Pediatric Emergency Medicine, King Faisal Specialist Hospital & Research Center (HAS), Riyadh, Saudi Arabia; International Emergency Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (PDA), Boston, MA; Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (MB); Emergency Medicine Ward and Observation Unit in Pisa Hospital (Italy) and Emergency Medicine, Tuscany Emergency Medicine Project in Collaboration With Harvard International (AB), Pisa, Italy; Anesthesiology and Emergency Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (AG); Catalan Health Service and at the EMS, Hospital Accreditation Service at Catalan Health Service, Catalan EMS, Catalan Emergency Integral Plan (SF), Catalonia; the Division of Emergency Care at Helsinki University Central Hospital (VPH), Helsinki, Finland; the Emergency Department at the Asklepios Hospital Hamburg-Altona (BH), Hamburg, Germany; Emergency Medicine, Olean General Hospital (VAK), Olean, NY; Emergency Medicine and Health Services Research, University of Sheffield (SM), Sheffield, UK; the Department of Emergency Medicine, Karolinska University Hospital (GO), Stockholm, Sweden; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong (TR), Hong Kong; the Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center (NKR), Springfield, MA; Prehospital and Emergency Medicine, Hospital of Victor Jousselin’s Hospital (ER), Dreux, France; NRMA-ACT, Australian National University Medical School, Emergency Medicine, The Canberra Hospital (DBR), Canberra, Australia; the Department of Emergency Medicine, George Washington University (MS [Iran]), Washington, DC; the Division of Emergency Medicine (Department of Medicine), University of Toronto, Institute for Clinical Evaluative Sciences, Emergency Medicine, Sunnybrook Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Harvard Medical School (BM), Boston, MA.
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  • Santiago Ferrandiz MD,

    1. From the Center for Health Care Quality and an Emergency Medicine and Health Policy, George Washington University (JMP), Washington, DC; the Department of Emergency Medicine, Hospital of the University of Pennsylvania (JAH), Philadelphia, PA; the Department of Emergency Medicine, University of California, San Francisco (EJW), San Francisco, CA; the Emergency Department, Langeland Hospital (AJA), Zoetermeer, the Netherlands; Pediatric Emergency Medicine, King Faisal Specialist Hospital & Research Center (HAS), Riyadh, Saudi Arabia; International Emergency Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (PDA), Boston, MA; Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (MB); Emergency Medicine Ward and Observation Unit in Pisa Hospital (Italy) and Emergency Medicine, Tuscany Emergency Medicine Project in Collaboration With Harvard International (AB), Pisa, Italy; Anesthesiology and Emergency Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (AG); Catalan Health Service and at the EMS, Hospital Accreditation Service at Catalan Health Service, Catalan EMS, Catalan Emergency Integral Plan (SF), Catalonia; the Division of Emergency Care at Helsinki University Central Hospital (VPH), Helsinki, Finland; the Emergency Department at the Asklepios Hospital Hamburg-Altona (BH), Hamburg, Germany; Emergency Medicine, Olean General Hospital (VAK), Olean, NY; Emergency Medicine and Health Services Research, University of Sheffield (SM), Sheffield, UK; the Department of Emergency Medicine, Karolinska University Hospital (GO), Stockholm, Sweden; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong (TR), Hong Kong; the Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center (NKR), Springfield, MA; Prehospital and Emergency Medicine, Hospital of Victor Jousselin’s Hospital (ER), Dreux, France; NRMA-ACT, Australian National University Medical School, Emergency Medicine, The Canberra Hospital (DBR), Canberra, Australia; the Department of Emergency Medicine, George Washington University (MS [Iran]), Washington, DC; the Division of Emergency Medicine (Department of Medicine), University of Toronto, Institute for Clinical Evaluative Sciences, Emergency Medicine, Sunnybrook Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Harvard Medical School (BM), Boston, MA.
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  • Vijaya Arun Kumar MD,

    1. From the Center for Health Care Quality and an Emergency Medicine and Health Policy, George Washington University (JMP), Washington, DC; the Department of Emergency Medicine, Hospital of the University of Pennsylvania (JAH), Philadelphia, PA; the Department of Emergency Medicine, University of California, San Francisco (EJW), San Francisco, CA; the Emergency Department, Langeland Hospital (AJA), Zoetermeer, the Netherlands; Pediatric Emergency Medicine, King Faisal Specialist Hospital & Research Center (HAS), Riyadh, Saudi Arabia; International Emergency Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (PDA), Boston, MA; Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (MB); Emergency Medicine Ward and Observation Unit in Pisa Hospital (Italy) and Emergency Medicine, Tuscany Emergency Medicine Project in Collaboration With Harvard International (AB), Pisa, Italy; Anesthesiology and Emergency Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (AG); Catalan Health Service and at the EMS, Hospital Accreditation Service at Catalan Health Service, Catalan EMS, Catalan Emergency Integral Plan (SF), Catalonia; the Division of Emergency Care at Helsinki University Central Hospital (VPH), Helsinki, Finland; the Emergency Department at the Asklepios Hospital Hamburg-Altona (BH), Hamburg, Germany; Emergency Medicine, Olean General Hospital (VAK), Olean, NY; Emergency Medicine and Health Services Research, University of Sheffield (SM), Sheffield, UK; the Department of Emergency Medicine, Karolinska University Hospital (GO), Stockholm, Sweden; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong (TR), Hong Kong; the Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center (NKR), Springfield, MA; Prehospital and Emergency Medicine, Hospital of Victor Jousselin’s Hospital (ER), Dreux, France; NRMA-ACT, Australian National University Medical School, Emergency Medicine, The Canberra Hospital (DBR), Canberra, Australia; the Department of Emergency Medicine, George Washington University (MS [Iran]), Washington, DC; the Division of Emergency Medicine (Department of Medicine), University of Toronto, Institute for Clinical Evaluative Sciences, Emergency Medicine, Sunnybrook Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Harvard Medical School (BM), Boston, MA.
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  • Veli-Pekka Harjola MD,

    1. From the Center for Health Care Quality and an Emergency Medicine and Health Policy, George Washington University (JMP), Washington, DC; the Department of Emergency Medicine, Hospital of the University of Pennsylvania (JAH), Philadelphia, PA; the Department of Emergency Medicine, University of California, San Francisco (EJW), San Francisco, CA; the Emergency Department, Langeland Hospital (AJA), Zoetermeer, the Netherlands; Pediatric Emergency Medicine, King Faisal Specialist Hospital & Research Center (HAS), Riyadh, Saudi Arabia; International Emergency Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (PDA), Boston, MA; Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (MB); Emergency Medicine Ward and Observation Unit in Pisa Hospital (Italy) and Emergency Medicine, Tuscany Emergency Medicine Project in Collaboration With Harvard International (AB), Pisa, Italy; Anesthesiology and Emergency Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (AG); Catalan Health Service and at the EMS, Hospital Accreditation Service at Catalan Health Service, Catalan EMS, Catalan Emergency Integral Plan (SF), Catalonia; the Division of Emergency Care at Helsinki University Central Hospital (VPH), Helsinki, Finland; the Emergency Department at the Asklepios Hospital Hamburg-Altona (BH), Hamburg, Germany; Emergency Medicine, Olean General Hospital (VAK), Olean, NY; Emergency Medicine and Health Services Research, University of Sheffield (SM), Sheffield, UK; the Department of Emergency Medicine, Karolinska University Hospital (GO), Stockholm, Sweden; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong (TR), Hong Kong; the Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center (NKR), Springfield, MA; Prehospital and Emergency Medicine, Hospital of Victor Jousselin’s Hospital (ER), Dreux, France; NRMA-ACT, Australian National University Medical School, Emergency Medicine, The Canberra Hospital (DBR), Canberra, Australia; the Department of Emergency Medicine, George Washington University (MS [Iran]), Washington, DC; the Division of Emergency Medicine (Department of Medicine), University of Toronto, Institute for Clinical Evaluative Sciences, Emergency Medicine, Sunnybrook Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Harvard Medical School (BM), Boston, MA.
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  • Barbara Hogan MD,

    1. From the Center for Health Care Quality and an Emergency Medicine and Health Policy, George Washington University (JMP), Washington, DC; the Department of Emergency Medicine, Hospital of the University of Pennsylvania (JAH), Philadelphia, PA; the Department of Emergency Medicine, University of California, San Francisco (EJW), San Francisco, CA; the Emergency Department, Langeland Hospital (AJA), Zoetermeer, the Netherlands; Pediatric Emergency Medicine, King Faisal Specialist Hospital & Research Center (HAS), Riyadh, Saudi Arabia; International Emergency Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (PDA), Boston, MA; Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (MB); Emergency Medicine Ward and Observation Unit in Pisa Hospital (Italy) and Emergency Medicine, Tuscany Emergency Medicine Project in Collaboration With Harvard International (AB), Pisa, Italy; Anesthesiology and Emergency Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (AG); Catalan Health Service and at the EMS, Hospital Accreditation Service at Catalan Health Service, Catalan EMS, Catalan Emergency Integral Plan (SF), Catalonia; the Division of Emergency Care at Helsinki University Central Hospital (VPH), Helsinki, Finland; the Emergency Department at the Asklepios Hospital Hamburg-Altona (BH), Hamburg, Germany; Emergency Medicine, Olean General Hospital (VAK), Olean, NY; Emergency Medicine and Health Services Research, University of Sheffield (SM), Sheffield, UK; the Department of Emergency Medicine, Karolinska University Hospital (GO), Stockholm, Sweden; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong (TR), Hong Kong; the Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center (NKR), Springfield, MA; Prehospital and Emergency Medicine, Hospital of Victor Jousselin’s Hospital (ER), Dreux, France; NRMA-ACT, Australian National University Medical School, Emergency Medicine, The Canberra Hospital (DBR), Canberra, Australia; the Department of Emergency Medicine, George Washington University (MS [Iran]), Washington, DC; the Division of Emergency Medicine (Department of Medicine), University of Toronto, Institute for Clinical Evaluative Sciences, Emergency Medicine, Sunnybrook Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Harvard Medical School (BM), Boston, MA.
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  • Bo Madsen MD, MPH,

    1. From the Center for Health Care Quality and an Emergency Medicine and Health Policy, George Washington University (JMP), Washington, DC; the Department of Emergency Medicine, Hospital of the University of Pennsylvania (JAH), Philadelphia, PA; the Department of Emergency Medicine, University of California, San Francisco (EJW), San Francisco, CA; the Emergency Department, Langeland Hospital (AJA), Zoetermeer, the Netherlands; Pediatric Emergency Medicine, King Faisal Specialist Hospital & Research Center (HAS), Riyadh, Saudi Arabia; International Emergency Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (PDA), Boston, MA; Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (MB); Emergency Medicine Ward and Observation Unit in Pisa Hospital (Italy) and Emergency Medicine, Tuscany Emergency Medicine Project in Collaboration With Harvard International (AB), Pisa, Italy; Anesthesiology and Emergency Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (AG); Catalan Health Service and at the EMS, Hospital Accreditation Service at Catalan Health Service, Catalan EMS, Catalan Emergency Integral Plan (SF), Catalonia; the Division of Emergency Care at Helsinki University Central Hospital (VPH), Helsinki, Finland; the Emergency Department at the Asklepios Hospital Hamburg-Altona (BH), Hamburg, Germany; Emergency Medicine, Olean General Hospital (VAK), Olean, NY; Emergency Medicine and Health Services Research, University of Sheffield (SM), Sheffield, UK; the Department of Emergency Medicine, Karolinska University Hospital (GO), Stockholm, Sweden; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong (TR), Hong Kong; the Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center (NKR), Springfield, MA; Prehospital and Emergency Medicine, Hospital of Victor Jousselin’s Hospital (ER), Dreux, France; NRMA-ACT, Australian National University Medical School, Emergency Medicine, The Canberra Hospital (DBR), Canberra, Australia; the Department of Emergency Medicine, George Washington University (MS [Iran]), Washington, DC; the Division of Emergency Medicine (Department of Medicine), University of Toronto, Institute for Clinical Evaluative Sciences, Emergency Medicine, Sunnybrook Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Harvard Medical School (BM), Boston, MA.
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  • Suzanne Mason MD,

    1. From the Center for Health Care Quality and an Emergency Medicine and Health Policy, George Washington University (JMP), Washington, DC; the Department of Emergency Medicine, Hospital of the University of Pennsylvania (JAH), Philadelphia, PA; the Department of Emergency Medicine, University of California, San Francisco (EJW), San Francisco, CA; the Emergency Department, Langeland Hospital (AJA), Zoetermeer, the Netherlands; Pediatric Emergency Medicine, King Faisal Specialist Hospital & Research Center (HAS), Riyadh, Saudi Arabia; International Emergency Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (PDA), Boston, MA; Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (MB); Emergency Medicine Ward and Observation Unit in Pisa Hospital (Italy) and Emergency Medicine, Tuscany Emergency Medicine Project in Collaboration With Harvard International (AB), Pisa, Italy; Anesthesiology and Emergency Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (AG); Catalan Health Service and at the EMS, Hospital Accreditation Service at Catalan Health Service, Catalan EMS, Catalan Emergency Integral Plan (SF), Catalonia; the Division of Emergency Care at Helsinki University Central Hospital (VPH), Helsinki, Finland; the Emergency Department at the Asklepios Hospital Hamburg-Altona (BH), Hamburg, Germany; Emergency Medicine, Olean General Hospital (VAK), Olean, NY; Emergency Medicine and Health Services Research, University of Sheffield (SM), Sheffield, UK; the Department of Emergency Medicine, Karolinska University Hospital (GO), Stockholm, Sweden; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong (TR), Hong Kong; the Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center (NKR), Springfield, MA; Prehospital and Emergency Medicine, Hospital of Victor Jousselin’s Hospital (ER), Dreux, France; NRMA-ACT, Australian National University Medical School, Emergency Medicine, The Canberra Hospital (DBR), Canberra, Australia; the Department of Emergency Medicine, George Washington University (MS [Iran]), Washington, DC; the Division of Emergency Medicine (Department of Medicine), University of Toronto, Institute for Clinical Evaluative Sciences, Emergency Medicine, Sunnybrook Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Harvard Medical School (BM), Boston, MA.
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  • Gunnar Öhlén MD, PhD,

    1. From the Center for Health Care Quality and an Emergency Medicine and Health Policy, George Washington University (JMP), Washington, DC; the Department of Emergency Medicine, Hospital of the University of Pennsylvania (JAH), Philadelphia, PA; the Department of Emergency Medicine, University of California, San Francisco (EJW), San Francisco, CA; the Emergency Department, Langeland Hospital (AJA), Zoetermeer, the Netherlands; Pediatric Emergency Medicine, King Faisal Specialist Hospital & Research Center (HAS), Riyadh, Saudi Arabia; International Emergency Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (PDA), Boston, MA; Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (MB); Emergency Medicine Ward and Observation Unit in Pisa Hospital (Italy) and Emergency Medicine, Tuscany Emergency Medicine Project in Collaboration With Harvard International (AB), Pisa, Italy; Anesthesiology and Emergency Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (AG); Catalan Health Service and at the EMS, Hospital Accreditation Service at Catalan Health Service, Catalan EMS, Catalan Emergency Integral Plan (SF), Catalonia; the Division of Emergency Care at Helsinki University Central Hospital (VPH), Helsinki, Finland; the Emergency Department at the Asklepios Hospital Hamburg-Altona (BH), Hamburg, Germany; Emergency Medicine, Olean General Hospital (VAK), Olean, NY; Emergency Medicine and Health Services Research, University of Sheffield (SM), Sheffield, UK; the Department of Emergency Medicine, Karolinska University Hospital (GO), Stockholm, Sweden; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong (TR), Hong Kong; the Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center (NKR), Springfield, MA; Prehospital and Emergency Medicine, Hospital of Victor Jousselin’s Hospital (ER), Dreux, France; NRMA-ACT, Australian National University Medical School, Emergency Medicine, The Canberra Hospital (DBR), Canberra, Australia; the Department of Emergency Medicine, George Washington University (MS [Iran]), Washington, DC; the Division of Emergency Medicine (Department of Medicine), University of Toronto, Institute for Clinical Evaluative Sciences, Emergency Medicine, Sunnybrook Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Harvard Medical School (BM), Boston, MA.
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  • Timothy Rainer MD,

    1. From the Center for Health Care Quality and an Emergency Medicine and Health Policy, George Washington University (JMP), Washington, DC; the Department of Emergency Medicine, Hospital of the University of Pennsylvania (JAH), Philadelphia, PA; the Department of Emergency Medicine, University of California, San Francisco (EJW), San Francisco, CA; the Emergency Department, Langeland Hospital (AJA), Zoetermeer, the Netherlands; Pediatric Emergency Medicine, King Faisal Specialist Hospital & Research Center (HAS), Riyadh, Saudi Arabia; International Emergency Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (PDA), Boston, MA; Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (MB); Emergency Medicine Ward and Observation Unit in Pisa Hospital (Italy) and Emergency Medicine, Tuscany Emergency Medicine Project in Collaboration With Harvard International (AB), Pisa, Italy; Anesthesiology and Emergency Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (AG); Catalan Health Service and at the EMS, Hospital Accreditation Service at Catalan Health Service, Catalan EMS, Catalan Emergency Integral Plan (SF), Catalonia; the Division of Emergency Care at Helsinki University Central Hospital (VPH), Helsinki, Finland; the Emergency Department at the Asklepios Hospital Hamburg-Altona (BH), Hamburg, Germany; Emergency Medicine, Olean General Hospital (VAK), Olean, NY; Emergency Medicine and Health Services Research, University of Sheffield (SM), Sheffield, UK; the Department of Emergency Medicine, Karolinska University Hospital (GO), Stockholm, Sweden; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong (TR), Hong Kong; the Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center (NKR), Springfield, MA; Prehospital and Emergency Medicine, Hospital of Victor Jousselin’s Hospital (ER), Dreux, France; NRMA-ACT, Australian National University Medical School, Emergency Medicine, The Canberra Hospital (DBR), Canberra, Australia; the Department of Emergency Medicine, George Washington University (MS [Iran]), Washington, DC; the Division of Emergency Medicine (Department of Medicine), University of Toronto, Institute for Clinical Evaluative Sciences, Emergency Medicine, Sunnybrook Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Harvard Medical School (BM), Boston, MA.
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  • Niels Rathlev MD,

    1. From the Center for Health Care Quality and an Emergency Medicine and Health Policy, George Washington University (JMP), Washington, DC; the Department of Emergency Medicine, Hospital of the University of Pennsylvania (JAH), Philadelphia, PA; the Department of Emergency Medicine, University of California, San Francisco (EJW), San Francisco, CA; the Emergency Department, Langeland Hospital (AJA), Zoetermeer, the Netherlands; Pediatric Emergency Medicine, King Faisal Specialist Hospital & Research Center (HAS), Riyadh, Saudi Arabia; International Emergency Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (PDA), Boston, MA; Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (MB); Emergency Medicine Ward and Observation Unit in Pisa Hospital (Italy) and Emergency Medicine, Tuscany Emergency Medicine Project in Collaboration With Harvard International (AB), Pisa, Italy; Anesthesiology and Emergency Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (AG); Catalan Health Service and at the EMS, Hospital Accreditation Service at Catalan Health Service, Catalan EMS, Catalan Emergency Integral Plan (SF), Catalonia; the Division of Emergency Care at Helsinki University Central Hospital (VPH), Helsinki, Finland; the Emergency Department at the Asklepios Hospital Hamburg-Altona (BH), Hamburg, Germany; Emergency Medicine, Olean General Hospital (VAK), Olean, NY; Emergency Medicine and Health Services Research, University of Sheffield (SM), Sheffield, UK; the Department of Emergency Medicine, Karolinska University Hospital (GO), Stockholm, Sweden; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong (TR), Hong Kong; the Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center (NKR), Springfield, MA; Prehospital and Emergency Medicine, Hospital of Victor Jousselin’s Hospital (ER), Dreux, France; NRMA-ACT, Australian National University Medical School, Emergency Medicine, The Canberra Hospital (DBR), Canberra, Australia; the Department of Emergency Medicine, George Washington University (MS [Iran]), Washington, DC; the Division of Emergency Medicine (Department of Medicine), University of Toronto, Institute for Clinical Evaluative Sciences, Emergency Medicine, Sunnybrook Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Harvard Medical School (BM), Boston, MA.
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  • Eric Revue MD,

    1. From the Center for Health Care Quality and an Emergency Medicine and Health Policy, George Washington University (JMP), Washington, DC; the Department of Emergency Medicine, Hospital of the University of Pennsylvania (JAH), Philadelphia, PA; the Department of Emergency Medicine, University of California, San Francisco (EJW), San Francisco, CA; the Emergency Department, Langeland Hospital (AJA), Zoetermeer, the Netherlands; Pediatric Emergency Medicine, King Faisal Specialist Hospital & Research Center (HAS), Riyadh, Saudi Arabia; International Emergency Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (PDA), Boston, MA; Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (MB); Emergency Medicine Ward and Observation Unit in Pisa Hospital (Italy) and Emergency Medicine, Tuscany Emergency Medicine Project in Collaboration With Harvard International (AB), Pisa, Italy; Anesthesiology and Emergency Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (AG); Catalan Health Service and at the EMS, Hospital Accreditation Service at Catalan Health Service, Catalan EMS, Catalan Emergency Integral Plan (SF), Catalonia; the Division of Emergency Care at Helsinki University Central Hospital (VPH), Helsinki, Finland; the Emergency Department at the Asklepios Hospital Hamburg-Altona (BH), Hamburg, Germany; Emergency Medicine, Olean General Hospital (VAK), Olean, NY; Emergency Medicine and Health Services Research, University of Sheffield (SM), Sheffield, UK; the Department of Emergency Medicine, Karolinska University Hospital (GO), Stockholm, Sweden; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong (TR), Hong Kong; the Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center (NKR), Springfield, MA; Prehospital and Emergency Medicine, Hospital of Victor Jousselin’s Hospital (ER), Dreux, France; NRMA-ACT, Australian National University Medical School, Emergency Medicine, The Canberra Hospital (DBR), Canberra, Australia; the Department of Emergency Medicine, George Washington University (MS [Iran]), Washington, DC; the Division of Emergency Medicine (Department of Medicine), University of Toronto, Institute for Clinical Evaluative Sciences, Emergency Medicine, Sunnybrook Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Harvard Medical School (BM), Boston, MA.
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  • Drew Richardson MBBS,

    1. From the Center for Health Care Quality and an Emergency Medicine and Health Policy, George Washington University (JMP), Washington, DC; the Department of Emergency Medicine, Hospital of the University of Pennsylvania (JAH), Philadelphia, PA; the Department of Emergency Medicine, University of California, San Francisco (EJW), San Francisco, CA; the Emergency Department, Langeland Hospital (AJA), Zoetermeer, the Netherlands; Pediatric Emergency Medicine, King Faisal Specialist Hospital & Research Center (HAS), Riyadh, Saudi Arabia; International Emergency Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (PDA), Boston, MA; Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (MB); Emergency Medicine Ward and Observation Unit in Pisa Hospital (Italy) and Emergency Medicine, Tuscany Emergency Medicine Project in Collaboration With Harvard International (AB), Pisa, Italy; Anesthesiology and Emergency Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (AG); Catalan Health Service and at the EMS, Hospital Accreditation Service at Catalan Health Service, Catalan EMS, Catalan Emergency Integral Plan (SF), Catalonia; the Division of Emergency Care at Helsinki University Central Hospital (VPH), Helsinki, Finland; the Emergency Department at the Asklepios Hospital Hamburg-Altona (BH), Hamburg, Germany; Emergency Medicine, Olean General Hospital (VAK), Olean, NY; Emergency Medicine and Health Services Research, University of Sheffield (SM), Sheffield, UK; the Department of Emergency Medicine, Karolinska University Hospital (GO), Stockholm, Sweden; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong (TR), Hong Kong; the Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center (NKR), Springfield, MA; Prehospital and Emergency Medicine, Hospital of Victor Jousselin’s Hospital (ER), Dreux, France; NRMA-ACT, Australian National University Medical School, Emergency Medicine, The Canberra Hospital (DBR), Canberra, Australia; the Department of Emergency Medicine, George Washington University (MS [Iran]), Washington, DC; the Division of Emergency Medicine (Department of Medicine), University of Toronto, Institute for Clinical Evaluative Sciences, Emergency Medicine, Sunnybrook Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Harvard Medical School (BM), Boston, MA.
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  • Mehdi Sattarian MD,

    1. From the Center for Health Care Quality and an Emergency Medicine and Health Policy, George Washington University (JMP), Washington, DC; the Department of Emergency Medicine, Hospital of the University of Pennsylvania (JAH), Philadelphia, PA; the Department of Emergency Medicine, University of California, San Francisco (EJW), San Francisco, CA; the Emergency Department, Langeland Hospital (AJA), Zoetermeer, the Netherlands; Pediatric Emergency Medicine, King Faisal Specialist Hospital & Research Center (HAS), Riyadh, Saudi Arabia; International Emergency Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (PDA), Boston, MA; Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (MB); Emergency Medicine Ward and Observation Unit in Pisa Hospital (Italy) and Emergency Medicine, Tuscany Emergency Medicine Project in Collaboration With Harvard International (AB), Pisa, Italy; Anesthesiology and Emergency Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (AG); Catalan Health Service and at the EMS, Hospital Accreditation Service at Catalan Health Service, Catalan EMS, Catalan Emergency Integral Plan (SF), Catalonia; the Division of Emergency Care at Helsinki University Central Hospital (VPH), Helsinki, Finland; the Emergency Department at the Asklepios Hospital Hamburg-Altona (BH), Hamburg, Germany; Emergency Medicine, Olean General Hospital (VAK), Olean, NY; Emergency Medicine and Health Services Research, University of Sheffield (SM), Sheffield, UK; the Department of Emergency Medicine, Karolinska University Hospital (GO), Stockholm, Sweden; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong (TR), Hong Kong; the Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center (NKR), Springfield, MA; Prehospital and Emergency Medicine, Hospital of Victor Jousselin’s Hospital (ER), Dreux, France; NRMA-ACT, Australian National University Medical School, Emergency Medicine, The Canberra Hospital (DBR), Canberra, Australia; the Department of Emergency Medicine, George Washington University (MS [Iran]), Washington, DC; the Division of Emergency Medicine (Department of Medicine), University of Toronto, Institute for Clinical Evaluative Sciences, Emergency Medicine, Sunnybrook Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Harvard Medical School (BM), Boston, MA.
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  • Michael J. Schull MD, MSc, FRCPC

    1. From the Center for Health Care Quality and an Emergency Medicine and Health Policy, George Washington University (JMP), Washington, DC; the Department of Emergency Medicine, Hospital of the University of Pennsylvania (JAH), Philadelphia, PA; the Department of Emergency Medicine, University of California, San Francisco (EJW), San Francisco, CA; the Emergency Department, Langeland Hospital (AJA), Zoetermeer, the Netherlands; Pediatric Emergency Medicine, King Faisal Specialist Hospital & Research Center (HAS), Riyadh, Saudi Arabia; International Emergency Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (PDA), Boston, MA; Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (MB); Emergency Medicine Ward and Observation Unit in Pisa Hospital (Italy) and Emergency Medicine, Tuscany Emergency Medicine Project in Collaboration With Harvard International (AB), Pisa, Italy; Anesthesiology and Emergency Department of Emergency Medicine, University Hospital of Leipzig, Leipzig, Germany (AG); Catalan Health Service and at the EMS, Hospital Accreditation Service at Catalan Health Service, Catalan EMS, Catalan Emergency Integral Plan (SF), Catalonia; the Division of Emergency Care at Helsinki University Central Hospital (VPH), Helsinki, Finland; the Emergency Department at the Asklepios Hospital Hamburg-Altona (BH), Hamburg, Germany; Emergency Medicine, Olean General Hospital (VAK), Olean, NY; Emergency Medicine and Health Services Research, University of Sheffield (SM), Sheffield, UK; the Department of Emergency Medicine, Karolinska University Hospital (GO), Stockholm, Sweden; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong (TR), Hong Kong; the Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center (NKR), Springfield, MA; Prehospital and Emergency Medicine, Hospital of Victor Jousselin’s Hospital (ER), Dreux, France; NRMA-ACT, Australian National University Medical School, Emergency Medicine, The Canberra Hospital (DBR), Canberra, Australia; the Department of Emergency Medicine, George Washington University (MS [Iran]), Washington, DC; the Division of Emergency Medicine (Department of Medicine), University of Toronto, Institute for Clinical Evaluative Sciences, Emergency Medicine, Sunnybrook Health Sciences Center (MS), Toronto, Ontario, Canada; and the Department of Emergency Medicine, Harvard Medical School (BM), Boston, MA.
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  • The authors have no relevant financial information or potential conflicts of interest to disclose.

  • Supervising Editor: Manish Shah, MD.

Address for correspondence and reprints: Jesse M. Pines, MD, MBA, MSCE; e-mail: jesse.pines@gwumc.edu.

Abstract

ACADEMIC EMERGENCY MEDICINE 2011; 18:1358–1370 © 2011 by the Society for Academic Emergency Medicine

Abstract

The maturation of emergency medicine (EM) as a specialty has coincided with dramatic increases in emergency department (ED) visit rates, both in the United States and around the world. ED crowding has become a public health problem where periodic supply and demand mismatches in ED and hospital resources cause long waiting times and delays in critical treatments. ED crowding has been associated with several negative clinical outcomes, including higher complication rates and mortality. This article describes emergency care systems and the extent of crowding across 15 countries outside of the United States: Australia, Canada, Denmark, Finland, France, Germany, Hong Kong, India, Iran, Italy, The Netherlands, Saudi Arabia, Catalonia (Spain), Sweden, and the United Kingdom. The authors are local emergency care leaders with knowledge of emergency care in their particular countries. Where available, data are provided about visit patterns in each country; however, for many of these countries, no national data are available on ED visits rates or crowding. For most of the countries included, there is both objective evidence of increases in ED visit rates and ED crowding and also subjective assessments of trends toward higher crowding in the ED. ED crowding appears to be worsening in many countries despite the presence of universal health coverage. Scandinavian countries with robust systems to manage acute care outside the ED do not report crowding is a major problem. The main cause for crowding identified by many authors is the boarding of admitted patients, similar to the United States. Many hospitals in these countries have implemented operational interventions to mitigate crowding in the ED, and some countries have imposed strict limits on ED length of stay (LOS), while others have no clear plan to mitigate crowding. An understanding of the causes and potential solutions implemented in these countries can provide a lens into how to mitigate ED crowding in the United States through health policy interventions and hospital operational changes.

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