Emergency department (ED) crowding results when available resources cannot meet the demand for emergency services. ED crowding has negative impacts on patients, health care workers, and the community. Primary considerations for reducing ED crowding include improving the quality of care, patient safety, patient experience, and the health of populations, as well as reducing the per capita cost of health care. Evaluating causes, effects, and seeking solutions to ED crowding can be done within a conceptual framework addressing input, throughput, and output factors. ED leaders must coordinate with hospital leadership, health system planners and policy decision makers, and those who provide pediatric care to address ED crowding. Proposed solutions in this policy statement promote the medical home and timely access to emergency care for children.
Introduction
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.
Conceptualizing ED Crowding
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
Solutions to ED Crowding
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
Recommendations
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.
. | WHO . | |||
---|---|---|---|---|
WHAT . | Pediatric Providers . | Health Care System Leaders . | Health Care Finance Planners . | Policymakers . |
• Advocate for the medical home, including adoption of financially sustainable models of comprehensive primary care that integrate mental health care (focus on ED input).6,18 | x | x | x | x |
• Support accessible outpatient resources considering patient- and family-centered factors for seeking care, including unscheduled visits and access to subspecialty care, (focus on ED input).5,13,18–21 | x | x | ||
• Advocate for incentives for extended or nontraditional hours of outpatient service (including weekends), unique efforts to coordinate care, such as school and community-based programs, and provision of efficient care (focus on ED input).22 | x | x | x | x |
• Extend access to the medical home through telemedicine services, support development of telehealth infrastructure, and advocate for payment for telehealth emergency services and consultations (focus on ED input and throughput).23 | x | x | x | x |
• Encourage and assist families with enrollment for health care coverage and advocate to reduce barriers to enrollment in health care coverage (focus on ED input and output).24 | x | x | ||
• Advocate for policies such as adequate graduate medical education primary care training positions and loan repayment, to provide for the workforce necessary to care for all children (focus on ED input and output).25 | x | x | x | |
• Support the development of inpatient and outpatient pediatric mental-behavioral health providers and facilities (focus on ED input and output).6,19,26 | x | x | x | x |
• Advocate for fully funded comprehensive mental-behavioral health services including early identification, school-based mental-behavioral health care, and integration with the medical home (focus on ED input and output).6,18,27–31 | x | x | x | x |
• Be knowledgeable about evolving delivery systems, such as telehealth, observation units, community-based response teams, and mobile integrated health programs, and advocate that they meet the needs of children by inclusion of pediatric subject matter experts in their implementation (focus on ED input and output).6,12,32–37 | x | x | x | x |
• Implement evidence-based throughput solutions, including triage strategies, early order initiation, streaming patient flow, and staffing alignment (focus on ED throughput).38,39 | x | x | ||
• Actively participate in health care payment and regulation strategies that may place mandates or incentives on ED efficiency measures such as lean methodology, clinical outcomes like morbidity and mortality or adverse outcomes, length of stay, and waiting times (focus on ED throughput).7,40–44 | x | x | x | x |
• Support pediatric readiness initiatives to use clinical care guidelines in EDs; have policies or processes that address children and youth with special health care needs (focus on ED throughput).17,45,46 | x | x | ||
• Maintain focus on hospital operations that will decrease boarding time in EDs; explore the use of capacity management monitoring systems; establish plans for caring for boarding patients (focus on ED output).8–11,14–16 | x | x | ||
• Plan for inpatient, critical care, and pediatric surge capacity (focus on ED output).1,47 | x | x | x | |
• Support research in ED crowding and health care utilization by children, including interventions focused on mitigating burnout in the health care workforce and optimal measures of crowding and its mitigation (focus on ED input, throughput, and output). | x | x | x |
. | WHO . | |||
---|---|---|---|---|
WHAT . | Pediatric Providers . | Health Care System Leaders . | Health Care Finance Planners . | Policymakers . |
• Advocate for the medical home, including adoption of financially sustainable models of comprehensive primary care that integrate mental health care (focus on ED input).6,18 | x | x | x | x |
• Support accessible outpatient resources considering patient- and family-centered factors for seeking care, including unscheduled visits and access to subspecialty care, (focus on ED input).5,13,18–21 | x | x | ||
• Advocate for incentives for extended or nontraditional hours of outpatient service (including weekends), unique efforts to coordinate care, such as school and community-based programs, and provision of efficient care (focus on ED input).22 | x | x | x | x |
• Extend access to the medical home through telemedicine services, support development of telehealth infrastructure, and advocate for payment for telehealth emergency services and consultations (focus on ED input and throughput).23 | x | x | x | x |
• Encourage and assist families with enrollment for health care coverage and advocate to reduce barriers to enrollment in health care coverage (focus on ED input and output).24 | x | x | ||
• Advocate for policies such as adequate graduate medical education primary care training positions and loan repayment, to provide for the workforce necessary to care for all children (focus on ED input and output).25 | x | x | x | |
• Support the development of inpatient and outpatient pediatric mental-behavioral health providers and facilities (focus on ED input and output).6,19,26 | x | x | x | x |
• Advocate for fully funded comprehensive mental-behavioral health services including early identification, school-based mental-behavioral health care, and integration with the medical home (focus on ED input and output).6,18,27–31 | x | x | x | x |
• Be knowledgeable about evolving delivery systems, such as telehealth, observation units, community-based response teams, and mobile integrated health programs, and advocate that they meet the needs of children by inclusion of pediatric subject matter experts in their implementation (focus on ED input and output).6,12,32–37 | x | x | x | x |
• Implement evidence-based throughput solutions, including triage strategies, early order initiation, streaming patient flow, and staffing alignment (focus on ED throughput).38,39 | x | x | ||
• Actively participate in health care payment and regulation strategies that may place mandates or incentives on ED efficiency measures such as lean methodology, clinical outcomes like morbidity and mortality or adverse outcomes, length of stay, and waiting times (focus on ED throughput).7,40–44 | x | x | x | x |
• Support pediatric readiness initiatives to use clinical care guidelines in EDs; have policies or processes that address children and youth with special health care needs (focus on ED throughput).17,45,46 | x | x | ||
• Maintain focus on hospital operations that will decrease boarding time in EDs; explore the use of capacity management monitoring systems; establish plans for caring for boarding patients (focus on ED output).8–11,14–16 | x | x | ||
• Plan for inpatient, critical care, and pediatric surge capacity (focus on ED output).1,47 | x | x | x | |
• Support research in ED crowding and health care utilization by children, including interventions focused on mitigating burnout in the health care workforce and optimal measures of crowding and its mitigation (focus on ED input, throughput, and output). | x | x | x |
Lead Authors
Toni K. Gross, MD, MPH, FAAP
Natalie E. Lane, MD, FAAP
Nathan L. Timm, MD, FAAP
AAP Committee on Pediatric Emergency Medicine, 2021–2022
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
Liaisons
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
Former Committee Members, 2018–2021
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
Former Liaisons, 2018–2021
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
Staff
Sue Tellez
Drs Gross and Lane collaborated on the draft statement; Dr Timm contributed to subsequent revisions as did the original statement author, Dr Steve Krug; members of the Committee on Pediatric Emergency Medicine provided guidance on content and key edits, and all authors reviewed and approved the final statement.
Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.
The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
COMPANION PAPER: A companion to this article can be found at http://www.pediatrics.org/cgi/doi/10.1542/peds.2022-060972.
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
References
Competing Interests
FINANCIAL/POTENTIAL CONFLICT OF INTEREST DISCLOSURE: The authors have indicated they have no potential conflicts of interest to disclose.
Comments
Role of Urgent Care to help alleviate Emergency Department Overcrowding
The article by Gross et al., accurately highlights many of the issues presently affecting Emergency Departments (ED) globally. However, a large part of a possible solution to some of these issues is wholly unaddressed in the paper. The emergence of urgent care centres (UCC) in various countries over recent decades has provided an alternate site for unscheduled, sporadic care for patients with minor acute illness and injury who might have otherwise sought care in the ED.
This topic has been explored in several studies. Notably, Allen et al. demonstrated that the opening of an UCC in a U.S. ZIP code produced a relative decrease of 17.2% in visits to the local ED during the hours the UCC was open. They also found the largest reduction (27%) occurred in non-urgent/low acuity ED visits (1). This data corroborate what has been our experience in New Zealand, where urgent care has been recognized as a specialty by the Medical Council of New Zealand since 2000. Studies on healthcare utilization for acute issues in New Zealand have actually demonstrated the lowest rate of ED use per capita among all the nations in the developed world (2).
In addition, in their study of co-located UCCs and EDs in Sweden, Raidla et al. found that wait times for patients triaged to the UCC were reduced compared to ED patients in terms of both time to physician (TTP) and overall length of stay in the department (LOS). They also found this came with substantial cost reduction when UCC visits were compared to the costs for similar patients seen in EDs (3). New Zealand and Sweden are not outliers either, the United Kingdom (UK) is also in the process of expanding access through the development of a network of UCCs. (4).
In the wake of the COVID-19 pandemic, there has been significant growth in the number of UCCs numbers across the USA (5). The Office of the Assistant Secretary for Preparedness and Response (ASPR) Technical Resources Assistance Center, and Information Exchange (TRACIE) have previously recommended increasing engagement of UCCs and their leaders with health care coalitions in the interest of increasing public access to acute care for the common, minor concerns that arise which do not require ED level care (6). UCCs are already serving our patients and communities in the U.S. and throughout the world. Collaboration between the Urgent Care and Emergency Medicine communities can ensure optimal care for patients with acute medical needs across the spectrum of severity. This cannot occur, however, without first a wider acknowledgment that UC is already here and it’s meeting an important need of off-loading lower acuity patients from already over-burdened EDs.
Yours sincerely,
Dr. Ivan Koay MBChB, MRCS, FRNZCUC, MD
References
1. Allen L, Cummings J, Hockenberry J The impact of urgent care centers on non-emergent emergency department visits Health Serv Res. 2021 Aug; 56(4): 721–730.
2. Royal New Zealand College of Urgent Care What is Urgent Care https://rnzcuc.org.nz/about/what-is-uc/
3. Raidla A, Darro K, Carlson T, et. al. Outcomes of Establishing an Urgent Care Centre in
the Same Location as an Emergency Department Sustainability 2020, 12, 8190; doi: 10.3390/su12198190
4. National Health Service England https://www.england.nhs.uk/urgent-emergency-care/about-uec/
5. Mesirow Investment Banking Year End 2022 Healthcare Sector Report
6. United States Department of Health and Human Services Medical Surge and the Role of Urgent Care Centers www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwir8KvZxrD-AhU0kFwKHaBpBV4QFnoECA0QAQ&url=https%3A%2F%2Ffiles.asprtracie.hhs.gov%2Fdocuments%2Faspr-tracie-medical-surge-and-the-role-of-urgent-care-centers.pdf&usg=AOvVaw0FjrOgLE_XaU9EPG20nMDH