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Hospital emergency department

Crowding in the ED: AAP guidance offers solutions to complex problem

February 20, 2023

Variable access to primary and subspecialty care coupled with patients’ preferences for convenient care can drive emergency department (ED) volume to levels beyond which resources are readily available. This condition is defined as ED crowding.

Studies demonstrate a correlation between ED crowding and inpatient mortality, increased medical errors, delayed time to medication administration and patients leaving without receiving care. Those working to decrease ED crowding aim to improve the quality of care, patient experience and population health, while reducing the per capita cost of health care.

An AAP policy statement and technical report from the Committee on Pediatric Emergency Medicine detail the evidence and provide recommendations for addressing overcrowding to improve the care of children. The documents, Crowding in the Emergency Department: Challenges and Recommendations for the Care of Children and Crowding in the Emergency Department: Challenges and Best Practices for the Care of Children, are available at and and will be published in the March issue of Pediatrics.

Pediatric implications

In the U.S., more than 80% of ED visits by children occur in EDs that are not at a children’s hospital. Therefore, it is important for pediatricians and leaders of pediatric systems of care to be aware that crowding in any ED can harm children by preventing access to quality emergency care. Pediatric experts can play a role in the development and publication of clinical practice guidelines to improve efficiency and quality of care in all EDs.

While the medical home manages chronic conditions better than EDs, few incentives exist for the medical home to meet the conveniences offered by a 24/7 ED.

In addition, the declaration of a national emergency in child and adolescent mental health pointed to the increase in emergency visits for mental-behavioral health services and long waits for inpatient beds.

Burden of boarding

Boarding patients in the ED when there is a lack of staffed inpatient beds is believed to be the primary contributor to ED crowding. EDs have felt this acutely during the recent surge in respiratory viruses. The American College of Emergency Physicians and 34 other organizations signed on to a letter ( describing examples of the burden of boarding, declaring ED boarding a public health emergency.

ED crowding is multifactorial, and solutions will require coordinated efforts across the health care delivery system.


The following are among 15 recommendations for pediatric providers, health care system leaders, health care finance planners and/or policymakers:

  • Advocate for the medical home, including adoption of sustainable models of primary care that integrate mental health care.
  • Advocate for incentives for extended or nontraditional hours of outpatient service, unique efforts to coordinate care and provision of efficient care.
  • Encourage/assist families with enrollment for health care coverage.
  • Advocate for fully funded comprehensive mental-behavioral health services.
  • Plan for surge capacity.
  • Implement evidence-based throughput solutions, including triage strategies, early order initiation, streaming patient flow and staffing alignment.

Dr. Gross is a lead author of the policy statement and technical report. She is a member of the AAP Committee on Pediatric Emergency Medicine.

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