Main Features and Control Strategies to Reduce Overcrowding in Emergency Departments: A Systematic Review of the Literature

Figures & data

Table 1 Main Causes of Ed Overcrowding Broken Down by Factor

Phase	Influencing Variables
Input	Population aging with increased demand for hospitalization
	Difficulties in accessing urgent healthcare services
	Distorted information provided by mass media
	Bad health education
	Mismanagement of treatable diseases at home
	Lack of seasonal disease prophylaxis
	Inappropriate hospitalization request
	Increase of the poor population with consequent difficulty to face health costs
	Failed intervention on ED Frequent Users
Throughput	Failure to optimize triage activities
	Architectural limits of ED department
	Excessive practice of defensive medicine
	Efficiency of diagnostic services
	Health care understaffing
	Collaboration lack between health personnel
Output	Hospital bed shortage
	Failure to identify available beds
	Shortage of hospital discharge rooms
	Delayed and prolonged discharge
	Lack of social services to facilitate difficult patients’ discharge

Table 2 Elegibility Criteria

Inclusion	Exclusion
Timeline 2012–2022	2011 ≤ Time > 2022
Age ≥ 13 anni	Age ≤ 12
Articles with proposed solutions	Systematic Reviews, Descriptive articles without solutions
English, German, Italian languages	Languages other than English, German, Italian
	Relationship between Sars-Cov2 virus and ED overcrowding
	Correlation with acute or chronic diseases/disorders

Figure 1 Flowchart of the search and selection process of articles according to the PRISMA statement. No automation tools were used to screen articles.

Figure 2 Source and type of articles selected for the review study.

Table 3 Causes and Consequences of Ed Overcrowding

Causes	Item
Structural causes	Shortage of ED physical space^Citation3,Citation4,Citation10
Technological causes	–
Human causes	Increase in unscheduled access^Citation3,Citation5,Citation9,Citation11–13
	Inadequate ED access^Citation5,Citation6,Citation10,Citation13–17
	Increase of elderly people^Citation15,Citation16,Citation18,Citation19
	Increased demand from patients for specialized care^Citation11,Citation17,Citation18
	Rising burden of chronic disease^Citation19
	Excessive diagnostic test demand^Citation5
	Defensive medicine^Citation6
Managerial causes	Rising Emergency Department closures^Citation3
	Increased patients waiting to be hospitalized^Citation5,Citation15,Citation17
	Insufficient numbers of health workers^Citation4,Citation10,Citation13–15,Citation20
	Lack of availability of beds^Citation3,Citation4,Citation6
	Flow patients’ Bad management^Citation12,Citation17,Citation21
	Ambulance diversion^Citation22
	Mismanagement resources allocation^Citation10,Citation16,Citation20
	Limited access to primary care^Citation15
	Reduced health funding^Citation13
	Inability to discharge patients^Citation6,Citation13,Citation23
	Delayed services and consultations^Citation4,Citation16,Citation21,Citation24
Outcomes
On patients	Increased in-hospital death^Citation4,Citation12,Citation14,Citation15,Citation19,Citation20,Citation23,Citation24
	Increased patients who left without complete assessment^Citation24
	Increased patients leaving the emergency room without being seen^Citation10,Citation12–14,Citation16–18,Citation20,Citation22
	Increased patients’ pain and suffering^Citation22
	Patient dissatisfaction^Citation13–15,Citation17,Citation19,Citation21–23
	Delay treatments^Citation16,Citation17,Citation23
	Inbed delay patients^Citation16
	Delay in identification and treatment^Citation6,Citation12
On healthcare workers	Increased of the preventable medical mistakes^Citation22
	Health workers burnout^Citation14,Citation17,Citation19,Citation20
	Decreased quality of care^Citation6,Citation11,Citation16,Citation17,Citation21
	Work related stress^Citation20
On the system	Maximum waiting time for medical examination > 4 h^Citation13
	Prolonged ED Lengths Of Stay^Citation3,Citation4,Citation10,Citation14–16,Citation18,Citation19,Citation23,Citation24
	Rising health care cost^Citation12,Citation13,Citation16,Citation17,Citation21
	Increased waiting time^Citation6,Citation12,Citation22
	Ambulance diversion^Citation12,Citation21
	Waste of medical resources^Citation6

Figure 3 Measurement scales used as indicators to monitor the phenomenon of overcrowding.

Table 4 Proposed Solutions to Overcome Ed Overcrowding

Actions involving input	Ensuring priority of hospitalization for ED patients^Citation4
	Transfers between institutions permetted only if there are no patients awaiting admission in the ED^Citation4
	Ambulances diversion to other hospitals presumed less crowded^Citation18
	Incentivizing patients with less serious conditions to see their family doctor first, before going to the ED^Citation16
	Addition of clinical assistant to each ED shift^Citation22
	Investing in primary care^Citation16,Citation17
	To build home care and post acute care resources such as long-term care or rehabilitation services^Citation6
	Forecasting emergency department flow^Citation3,Citation10,Citation17
	Transference of admitted patients out of the ED rooms and into inpatient hallways^Citation15,Citation19
	Discourage boarding of admitted patients in ED exam rooms^Citation14
Actions involving throughput	Time-series analysis used to develop statistical models in order to forecast the patients flow in the ED^Citation10
	Increase bed of internal medicine^Citation19
	Increase outflow of internal medicine patients from the ED to the internal medicine departments^Citation19
	The access block viewed as a whole hospital problem and not only an ED problem^Citation23
	The creation of a Patient Partner role^Citation21
	Adding a dedicated triage space for patients who arrive by emergency medical services (EMS triage)^Citation13,Citation14
	Establishment of a rapid assessment unit (RAU) in ED^Citation21
	Decrease requests for unnecessary advance diagnostic tests^Citation5
	Development of a dashboard which provides real-time information regarding ED crowding^Citation20
	Early identification of events that may worsen patient’s health^Citation24
	Create a real time tool to inform patients about waiting times^Citation17,Citation22
	Improve the ED information system^Citation5,Citation6,Citation20
	Improve patients post acute care^Citation6
	Having a comprehensive view of patient flow in ED^Citation3
	Optimize staff and resources^Citation3,Citation10,Citation15,Citation18,Citation23
	Implementing additional resources and alternate care pathways^Citation3
	Hospital beds priority at ED^Citation4
	Patients registration process simply and fast^Citation15,Citation21
	Early identification of patients needing hospitalization or discharge^Citation24
	Earlier administration of important therapies such as analgesia and antibiotics^Citation24
	Close monitoring of specialties with the highest percentage of emergency room visits (cardiology, gastroenterology and pulmonology)^Citation11
	Supplemented Triage and Rapid Treatment (START)^Citation24
	Improve triage effectiveness^Citation12
	Speed up the request for necessary diagnostic tests^Citation5,Citation24
Actions involving output	Increased partnerships with social care service providers to facilitate discharge^Citation13
	To follow in the clinic patients already evaluated for the first time in the ED^Citation11
	Discharge of ED patients before 12:00 and discharge of internal medicine patients by the morning shift^Citation19
	Review of all patients in hospital for 14 days or more^Citation13
	Decanting non-emergency lower acuity patients from the ED to a primary care clinic^Citation16

Figure 4 ED overcrowding: identified causes, consequences and implemented strategies.

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