It is no surprise that emergency departments in United States hospitals are crowded. Nearly half of EDs report operating at or above capacity, and nine out of 10 hospitals report holding or "boarding" admitted patients in the ED while they await inpatient beds. Because of ED crowding, 500,000 ambulances are diverted each year to a hospital farther away. ED crowding has been the subject of countless news articles, lawsuits and research studies, and in 2006, the Institute of Medicine declared hospital-based emergency care "at the breaking point."

To date, the knowledge that EDs are overcrowded has not been sufficient to stimulate a groundswell of effort among hospitals to implement institutional solutions. Greater attention to the issue by hospital and health system boards may help drive improvement. Specifically, board members should request data on ED crowding measures collected at their organizations and ask CEOs what is being done to reduce crowding.

Although boards are tasked with overseeing a hospital's performance along many dimensions, the state of emergency care arguably warrants greater attention for four reasons.

Crowding Impacts Quality

EDs are high-risk, high-stress environments. When capacity is exceeded, there are heightened opportunities for error. The IOM's six dimensions of quality (safety, effectiveness, patient-centeredness, efficiency, timeliness and equity) may all be compromised when patients experience long waits to see a physician, patients are boarded in the ED or ambulances are diverted.

Over the past few years, several studies have presented clear evidence that ED crowding contributes to poor quality care. According to the Joint Commission, EDs are the source of just over one-half of all reported sentinel event cases of patient death or permanent injury due to delays in treatment; overcrowding is the root cause in about one-third of these cases.

ED crowding has been shown to be associated with increased door-to-needle times for patients with suspected acute myocardial infarction, lower likelihood of patients with community-acquired pneumonia to receive timely antibiotic therapy, poor pain management for geriatric patients, and lower patient satisfaction scores.

Addressing ED crowding may be a first step toward bringing your organization closer to achieving its quality goals.

Crowding Is Costly

In 2006, the most recent year of data available, 2.4 million people—percent of all ED visits—left the ED before being seen by a provider, typically because of long wait times. These walk-outs represent significant lost revenue for hospitals. The same is true of ambulance diversions. A 2006 study at a large academic medical center found that each hour on diversion was associated with $1,086 in foregone hospital revenues.

Further, odds are good that your organization will have to report ED crowding-related measures to the Centers for Medicare & Medicaid Services in the future as part of its expanding pay-for-performance program. In its 2010 final rules, CMS announced that it is considering three ED crowding-related measures that would have implications for payment in 2012:

  • Median time from ED arrival to departure for admitted patients
  • Median time from ED arrival to departure for discharged patients
  • Median time from admit decision to time of departure for admitted patients.

The first two measures represent length of stay in the ED, and the third is a measure of boarding in the ED. All three have been endorsed by the National Quality Forum. If your hospital does not currently collect data on these measures, it should begin doing so as soon as possible.

Although there are no national data available for comparison, national data on more commonly collected measures of crowding and ED patient flow are available. (For example, the median wait time to see a physician in the ED is 31 minutes nationally.) Senior hospital leaders and board members should request that measures of ED crowding be included on quality dashboards.

Crowding Compromises Community Trust

The ED plays a critical role within the community. There is a public expectation that EDs are capable of providing appropriate, timely care 24 hours a day, seven days a week. Because of the high volumes that many EDs experience, it may be the clinical area that the public is most familiar with, thereby making it the de facto "public face" of the organization.

When crowding leads to long wait times and a decreased ability to protect patient privacy and provide patient-centered care, the community's trust and confidence in the organization may be compromised.

Importantly, crowding also diminishes hospitals' ability to protect and care for the public in the event of a disaster or public health emergency. A recent survey by the Committee on Oversight and Government Relations of real-time capacity at Level 1 trauma centers in seven major cities found that none had sufficient capacity to respond to a sudden mass casualty event that would generate a large number of casualties.

If ED crowding at your hospital compromises your ability to offer access to emergent, life-saving care, the hospital may not be living up to its most important responsibility to the community.

Crowding Can Be Eased or Fixed

During the past several years, a lot of effort has been devoted to investigating the sources of ED crowding and developing potential solutions. One of the biggest has been the Robert Wood Johnson Foundation-funded Urgent Matters Initiative.

In 2006, Urgent Matters recruited 10 large, urban hospitals—hospitals with some of the most crowded EDs in the country—and offered technical assistance as they implemented various strategies to reduce crowding and improve patient flow. The result of this effort was remarkable. Participating hospitals dramatically improved patient flow without investing significant financial resources.

There are two key outcomes from the Urgent Matters collaborative that will be useful to other hospitals as they address ED crowding. The first is a toolkit of strategies that hospitals can adopt to improve patient flow. That toolkit will be available on the RWJF Web site this spring.

Second, the collaborative revealed four factors critical to the successful implementation of initiatives to reduce ED crowding:

  • collection of key performance measures;
  • implementation of formal improvement methods;
  • creation of multidisciplinary teams to oversee the process; and
  • support of hospital leaders, including the CEO.

In 2008, a second Urgent Matters collaborative was launched with a more diverse group of hospitals. The participating hospitals selected improvement strategies from the Urgent Matters toolkit or designed new strategies to address a variety of bottlenecks including difficulty moving admitted ED patients to inpatient beds, delays in getting a specialty consult, and inefficient triage and registration processes.

While the collaborative is still under way, early findings indicate that strategies designed to reduce ED crowding can be successfully adopted by many different types of hospitals, and they can be implemented with existing resources.

Bottom Line

Several surveys show that ED crowding is a top concern for ED physicians and nurses, and efforts aimed at reducing crowding appear to be largely driven by them. However, the primary cause of crowding lies not in the ED, but within other parts of the hospital.

Capacity constraints and barriers to the efficient flow of patients in inpatient units often prohibit ED staff from moving admitted patients out of the ED. This is the foremost source of ED crowding, and it cannot be fixed by ED staff alone.

A commitment from senior hospital and health system leaders to address the institutional barriers is needed. Because ED crowding has a direct impact on hospital operations, quality of care, finances and community relations, boards should take an active interest in understanding the extent of the problem within their organizations and what is being done to address it.

For more information on the Urgent Matters project, go to

Megan McHugh, PH.D. (, is director of research at the Health Research & Educational Trust, an affiliate of the American Hospital Association, Chicago.