Crowding in the Emergency Department: Challenges and Recommendations for the Care of Children

Emergency department (ED) crowding occurs when the need for emergency services outstrips available resources in the ED.¹  ED crowding negatively impacts patient safety, patient experience, and staff engagement. Hospital fiscal stability and community access to health care are also affected by ED crowding. EDs are often the safety net for health care services in a community and must also remain prepared for disasters and pandemics.

The number of pediatric ED visits has been increasing.²  Over 80% of pediatric emergency department visits occur in nonchildren’s hospitals.³  Children seeking emergency care present unique challenges when addressing ED crowding in both general and pediatric EDs. Even with adequate pediatric readiness, general emergency centers risk missing an ill child among a large number of patients, including children with lower urgency complaints.

ED crowding is multifactorial and cannot be solved solely by those who manage and provide care in EDs. This policy statement presents evidence-based solutions aimed at primary care providers, ED leaders, hospital administrators, health care system planners, and health care regulatory bodies.

A conceptual model of ED crowding is presented in Fig 1, providing a framework for recommendations to focus on input, throughput, and output.⁴  Input is the number of patients seeking emergency care, including those arriving by ambulance or being referred to the ED. Throughput is the length of time that patients spend from arrival to departure in the ED. Output is the movement of patients out of the ED to home, hospital admission, or other health care facilities, and can involve referrals to specialty services.

Drivers for ED utilization are multifactorial, and access to primary and subspecialty care providers is variable. Patient- and family-centered preferences for care outside of typical school and work hours may also drive patients to general and pediatric EDs for care.⁵  Conditions leading to the National State of Emergency in Children’s Mental Health⁶  have created additional demand for emergency care. The American Academy of Pediatrics (AAP) technical report on flow and pediatric care in an emergency department defines throughput factors that are key to ED crowding.⁷  Boarding, or holding an admitted patient in the ED, typically because of a lack of available staffed inpatient beds, hinders output and is believed to be one of the primary contributors to ED crowding.^8–11 

At the heart of ED crowding is the concern for patient safety. Generally, there is a consensus that the solution to ED crowding cannot be solved within the ED alone. ED crowding at a local level is a hospital system issue, requiring hospital leadership to recognize the input, throughput, and output variables that may be adjustable outside of the ED. Cooperation within the health care system regionally or nationally has the potential to create opportunities for improvement. When examining solutions to ED crowding, two strategies could be considered: reducing the amount of ED crowding and mitigating the negative effects of ED crowding.

The medical home better manages chronic conditions, decreasing the need for emergency care by preventing or treating and mitigating exacerbations of illness. Knowledge of key predictors of ED use may allow pediatricians to effectuate reduction of ED use in some circumstances. The Milken Institute School of Public Health recommends increasing access to primary care.⁸  Alternate hours primary care options would provide additional opportunity for patients to receive care at the medical home, allowing families to seek care in a clinic setting and avoid missed school and work. An evolving emergency medical services (EMS) field of community paramedicine, where paramedics operate in expanded roles using mobile integrated health to create collaboration among health and social services disciplines,¹²  is garnering the attention of federal funders and pilot programs have shown promise in reducing ED crowding.

Addressing access to specialty care, especially mental-behavioral health services during a National State of Emergency in Children’s Mental Health,⁶  while paying attention to disparities in access, will allow children to receive subspecialty care in a timely fashion.¹³  Several examples of alternative models are given in the accompanying technical report. The AAP recommends accelerating adoption of effective and financially sustainable models of integrated mental health in care in primary care pediatrics, including strategies and models for payment.⁶ 

ED staffing levels and roles, room distribution, triage teams, and streaming patient flow can have effects on throughput in all EDs. Following lean methodology of parallel processing and organizing supplies and equipment to reduce steps, as well as ensuring efficiency of ancillary hospital services, are additional solutions.

Hospital- and health care system-wide processes for streamlining admission to the hospital will decrease boarding time in the ED. Capacity alert systems unify efforts to reduce ED crowding by enlisting increased resources from departments outside of the ED. Daily safety updates keep hospital leadership abreast of crowding in the ED. Earlier inpatient discharges have been shown to decrease ED crowding and patient boarding hours.^14,15  Hospitals with a dedicated observation unit have achieved earlier median discharge times.¹⁶ 

Hospital and ED leadership should anticipate the unintended consequences of exhausting all possible capacity for urgent surge in the event of a disaster or mass casualty incident involving ill or injured children. Efforts to optimize day-to-day capacity while minimizing costs associated with rarely used space and resources should not unduly compromise the hospital’s and community’s ability to meet critical need during a crisis or disaster. Global and systemic causes of crowding, including hospital funding, require emergency medicine leadership to be actively involved at all levels.¹ 

The use of clinical practice guidelines or pathways may improve not only efficiency but also quality of patient care.⁷  Financially incentivized pathways, including pay-for-performance pediatric-specific metrics, may have a positive effect on ensuring standardized quality care for children in all EDs.¹⁷ 

ED crowding is a complex problem, and necessarily, solutions will require coordinated efforts across the health care delivery system. At the heart of reducing ED crowding are the common aims of improving the quality of care, patient safety, and patient experience, improving the health of populations and reducing the per capita cost of health care.

There is no single approach that can principally affect the issue of crowding in EDs. Assessing potential factors that could be contributing to the issue and addressing them will be important to improve the care of children and the effects of crowding on patients and care providers. Mitigating the negative impact ED crowding has on health care worker wellness will address the attrition leading to staffing shortages. For the pediatrician, actively engaging with health care systems and policymakers as well as patient education are important contributions to helping solve the problem of crowding in EDs.

The following recommendations are for pediatric providers, health care system leaders, health care finance planners, and policymakers.

Toni K. Gross, MD, MPH, FAAP

Natalie E. Lane, MD, FAAP

Nathan L. Timm, MD, FAAP

Gregory P. Conners, MD, MPH, MBA, FAAP, Chairperson

Toni Gross, MD, MPH, FAAP

Jennifer Hoffmann, MD, FAAP

Benson Hsu, MD, MBA, FAAP

Lois Lee, MD, MPH, FAAP

Jennifer Marin, MD, MSc, FAAP

Suzan Mazor, MD, FAAP

Ronald Paul, MD, FAAP

Mohsen Saidinejad, MD, MS, MBA, FAAP

Muhammad Waseem, MBBS, FAAP

Mark Cicero, MD, FAAP – National Association of EMS Physicians

Paul Ishimine, MD, FACEP, FAAP – American College of Emergency Physicians

Andrew Eisenberg, MD, MHA – American Academy of Family Physicians

Mary Fallat, MD, FAAP – American College of Surgeons

Patricia Fanflik, PhD, MFT, MS – Maternal and Child Health Bureau

Cynthia Wright Johnson, MSN, RN – National Association of State EMS Officials

Sara Kinsman, MD, PhD, FAAP – Maternal and Child Health Bureau

Cynthiana Lightfoot, BFA, NRP – AAP Family Partnerships Network

Charles Macias, MD, MPH, FAAP – EMSC Innovation and Improvement Center

Katherine Remick, MD, FAAP – National Association of Emergency Medical Technicians

Sam Shahid, MBBS, MPH – American College of Emergency Physicians

Elizabeth Stone, RN, PhD, CPEN – Emergency Nurses Association

Joseph Wright, MD, MPH, FAAP, Chairperson (2016–2020)

James Callahan, MD, FAAP

Javier Gonzalez del Rey, MD, MEd, FAAP

Madeline Joseph, MD, FAAP

Elizabeth Mack, MD, MS, FAAP

Nathan Timm, MD, FAAP

Ann Dietrich, MD, FACEP – American College of Emergency Physicians

Brian Moore, MD, FAAP – National Association of EMS Physicians

Diane Pilkey, RN, MPH – Maternal and Child Health Bureau

Mohsen Saidinejad, MD, MBA, FAAP, FACEP – American College of Emergency Physicians

Sally Snow, RN, BSN, CPEN, FAEN – Emergency Nurses Association

Sue Tellez

AAP

American Academy of Pediatrics

ED

emergency department

EMS

emergency medical services