Three Strategies for Improving Emergency Department Flow, Crowding


Crowding of the emergency department can often affect health outcomes for patients and even contribute to patient readmissions, creating a vicious cycle for an already troubling crowding problem. 


Emergency departments across the U.S. are burdened by crowding conditions on a daily basis. Many departments are experiencing unusually high growth in volume each year, compounded by unwavering ripple effects of hospital closures nationwide

Crowding of the emergency department can often adversely affect health outcomes for patients and even contribute to patient readmissions, creating a vicious cycle for an already troubling crowding problem. This has made it that much more imperative that hospitals identify solutions to ease crowding in their emergency departments.

Hospital leadership should consider three strategies for addressing this issue in their emergency departments head on:

Reevaluate front-end processes to provide patients timely care

Many facilities continue to triage patients upon arrival, even though beds are open and available in the department. If a bed is available, the triage process should no longer be necessary. Patients should be immediately bedded so they can be cared for more quickly and expedite their stay.

Related: Effective Transitions of Care After Discharge Process

Hospitals should also more critically evaluate their process or policy for holding beds open for critical patients. While these patients do need more immediate care, ED leadership should evaluate the Emergency Severity Index (ESI) data to determine the number of ESI level-1 patients moving through the department on a daily basis. They can then use this data to determine if it's justified to leave a bed open 24 hours a day or more efficient to use the bed and move a patient out of a room when a critical patient is en route.

Provide care in appropriate care spaces

When there are no beds available in the department, assigning an appropriate acuity upon arrival allows emergency department staff to better prioritize and identify patients needing emergent care, as well as sort and direct patients to the most appropriate care space. This may be the trauma bay, fast track, or a vertical treatment space.

Emergency departments have discovered that providing care while keeping a patient vertical helps to reduce their length of stay. Departments should evaluate their processes and identify ways to provide care to patients in vertical spaces, such as chairs, when possible. This will help decrease the overall length of stay for patients in the department and help departments provide care to a larger number of patients.

Eliminate unnecessary boarding by evaluating inpatient processes

Lastly, it's important to recognize all patients in the emergency department are the responsibility of the facility as a whole. In an effort to eliminate patient boarding, facilities should evaluate inpatient processes and identify methods to promote progression to discharge.

Discharge lounges, high-quality multi-disciplinary meetings, and evaluation of contracts to ensure 24/7 services are provided to the facility are all examples of ways hospitals can make reducing patient boarding a priority.

Emergency departments must recognize that broken or cumbersome processes have a severe impact on the flow in the emergency department and how important it is to complete quality performance improvement work.

Armed with the knowledge emergency department boarding decreases the number of spaces available to care for emergent patients, hospital leadership must implement tactics focused on increasing throughput and eliminating barriers to care.

For instance, in 2013, when The Joint Commission developed standards around emergency department boarding, some facilities elected to train its nurses to document on the inpatient nursing templates. While this may meet the standard, it does not do enough to actually promote high-quality patient care for boarding inpatients, limits the ability of the emergency room personnel to provide care to arriving patients, and does not increase throughput. 

When quality of care and the ability to provide better health outcomes is impacted by crowding in the emergency department, hospital leadership needs to take notice. This is a problem that is not going away, but currently getting worse due to other pressures put on our health system in the U.S.

These three tactics should be a strong starting point for emergency departments to reevaluate their existing processes, but hospital leadership needs to generally look more closely at the flow of their patients and identify opportunities for improvement in the length of stay for their most acute patients.

Larry Faulkner is senior consultant, Philips, and certified emergency nurse with years of experience in providing clinical and leadership expertise in the emergency care setting. He is passionate about providing patient-focused care and as an ED director, he has successfully implemented evidence-based leadership tactics including leadership/staff/hourly rounding and bedside shift reporting.

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