One of the most concerning challenges to Emergency Department (ED) nurses is ED crowding. Though it has its most profound effect on the ED, the contributing factors have their origins beyond the doors of the ED. More importantly, the effects are felt both in the community and in the hospital.

ED crowding is not a new challenge. It is discussed in articles published as early as 1991. The Institute of Medicine published “Hospital-Based Emergency Care: At the Breaking Point which defined and described this phenomenon. The Emergency Nurses Association (ENA) White Paper on Crowding in the Emergency Department reports that between 1993 and 2003 the number of ED visits increased by 26% in the US. At the same time, there were 12% fewer EDs and an unspecified number of hospital closures.

The US population is living longer resulting in more people having chronic illness requiring more complex care and longer hospital stays. With increased unemployment, the number of uninsured and underinsured patients is increasing. These patients are more likely to rely on the ED for primary care typically wait longer before seeking care and are sicker, requiring longer stays in the ED, more ED resources, eventual hospitalization, and longer hospital stays. The net effect is more patients coming to the ED for care, fewer inpatient beds for those that need admission resulting in fewer beds for new arrivals to the ED.

The doors of the ED, by law, are always open making it nearly impossible to stem the tide. Because of this, incoming patients are seen in areas not designed for patient care such as hallways or must wait until a treatment space becomes available. Some will not wait and leave before treatment is completed or even before being seen by ED staff. In an article entitled, “Emergency Department Crowding: A Call to Action in the New Year,” Bill Briggs, the ENA President describes ED crowding as a disease (Journal of Emergency Nursing, 1/09, p 1). He says that research reveals that the consequences of crowding are delay in diagnosis, increased, walk-outs of patients needing care, increased medical errors, ambulance diversions, increased hospital length of stay, increased negligence claims, and increased mortality.

The upstream effect is concerning as well. More and more, Emergency Medical Services (EMS) crews have to wait for ED staff to make a place for them to put their patient in the ED. In most communities, EMS systems are stretched to the limit. Waiting in the ED delays the crew’s return to service. Additionally, ambulance diversions, when the ED asks EMS crews to bypass that ED because crowding has sapped nearly all resources, have been increasing as well. This further lengthens the time before returning to service. The strain on the other hospitals in the community can be worsened. This can be a dangerous combination even under normal conditions. If even a small scale disaster were to occur in the community, the effects could be devastating.

Many agencies and groups have turned their attention to solving ED crowding. The Joint Commission developed standards that require hospitals to measure ED crowding and patient flow in the hospital. These standards stress the need to improve flow throughout the hospital as a means of reducing crowding. Many hospitals have developed ways to improve flow. Strategies include improving processes in the ED to reduce overall wait times, involving all inpatient units in examine staffing and inpatient bed availability on a daily basis or more frequently, admission holding areas to clear admitted patients from ED beds, discharge holding areas to clear inpatient beds sooner, developing indicators for monitoring patient flow and bed capacity and early warning criteria to adjust patient flow before crowding impairs the ability to provide safe patient care.