Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals

Section 1. The Need to Address Emergency Department Crowding

Many emergency departments (EDs) across the country are crowded. Nearly half of EDs report operating at or above capacity, and 9 out of 10 hospitals report holding or "boarding" admitted patients in the ED while they await inpatient beds. Because of crowding, approximately 500,000 ambulances are diverted each year away from the closest hospital. ED crowding has been the subject of countless news articles, lawsuits, and research studies.

Although you, the hospital or ED leaders, are responsible for overseeing hospital performance across a number of dimensions, there are several reasons why addressing ED crowding should be at the forefront of your organizations' improvement efforts. These include:

1. ED Crowding Compromises Care Quality

EDs are high-risk, high-stress environments. When capacity is exceeded, there are heightened opportunities for error. The Institute of Medicine's (IOM's) six dimensions of quality (safety, effectiveness, patient-centeredness, efficiency, timeliness, and equity) may all be compromised when patients experience long waits to see a physician, patients are boarded in the ED, or ambulances are diverted away from the hospital closest to the patient. Over the past few years, several studies have presented clear evidence that ED crowding contributes to poor quality care.1-5

2. ED Crowding Is Costly

In 2007, the most recent year for which data are available, 1.9 million people—representing 2 percent of all ED visits—left the ED before being seen, typically because of long wait times.6 These walk-outs represent significant lost revenue for hospitals. The same is true of ambulance diversions. A 2006 study at a large academic medical center (AMC) found that each hour on diversion was associated with $1,086 in foregone hospital revenues.7 A more recent study conducted at a different AMC showed that a 1-hour reduction in ED boarding time would result in over $9,000 of additional revenue by reducing ambulance diversion and the number of patients who left without being seen.8 A crowded ED also limits the ability of an institution to accept referrals and increases medicolegal risks.

3. Hospitals Will Soon Report ED Crowding Measures to CMS

The Centers for Medicare & Medicaid Services (CMS) announced the inclusion of five ED crowding related measures under the Hospital Inpatient Quality Reporting Programa initiative:

  • Patient median time from ED arrival to ED departure for discharged patients (calendar year [CY] 2013).
  • Door-to-diagnostic evaluation by a qualified medical professional (CY 2013).
  • Patient left before being seen (CY 2013).
  • Median time from ED arrival to ED departure for admitted patients (FY 2014).
  • Median time from admit decision time to time of departure for admitted patients (FY 2014).

Hospitals will be required to report these measures to CMS in order to receive the full Medicare payment update.9,10 The measures were endorsed by the National Quality Forum in 2008,11 and they are commonly used by researchers to assess changes in ED crowding and patient throughput. Eventually, these measures will be reported publicly.

4. ED Crowding Compromises Community Trust

The ED plays a critical role within the community. There is a public expectation that EDs are capable of providing appropriate, timely care 24/7, and that they will have the capacity to protect and care for the public in the event of a disaster or public health emergency. In addition, there is evidence showing that physicians and clinics refer patients to the ED for a variety of reasons,12 including convenience for after-hours care, reluctance to take on complex cases, liability concerns, and the need for diagnostic testing that cannot be performed in their offices. Because of the high patient volumes that many EDs experience, the ED may be the clinical area that the public is most familiar with, thereby making it the de facto"public face" of the organization. When crowding leads to long wait times and a decreased ability to protect patient privacy and provide patient-centered care, the community's trust and confidence in the organization may be compromised.

5. ED Crowding Can Be Mitigated by Improving Patient Flow

Over the past several years, much effort has been devoted to investigating the sources of ED crowding and developing potential solutions. Based on that effort, there is widespread agreement that improving the flow of patients in the ED and throughout the hospital holds promise for addressing ED crowding. A number of hospitals have implemented patient flow improvement strategies that have resulted in reductions in measures of ED crowding. As a result, numerous organizations—including the Institute for Healthcare Improvement, the Joint Commission, and the Institute of Medicine—have encouraged hospital leaders to adopt patient flow improvements.12-14

The purpose of this guide is to present step-by-step instructions for planning and implementing patient flow improvement strategies. The guide contains real-world examples of how hospitals have implemented these steps, the pitfalls they encountered, and strategies used to overcome them. The guide is intended for a broad audience, including hospital chief executive officers, chief quality officers, risk managers, ED directors, ED clinicians and staff, and others with an interest in reducing ED crowding.

The information in this guide was compiled from the experiences of the hospitals affiliated with Urgent Matters, a national program funded by the Robert Wood Johnson Foundation dedicated to finding, developing, and disseminating strategies to improve patient flow and reduce ED crowding. In 2002, Urgent Matters launched its first learning network with 10 hospitals. The hospitals worked together in a collaborative learning process and received technical assistance to develop and implement best practices to address ED crowding. Results are summarized in the report Bursting at the Seams: Improving Patient Flow.15 In 2008, Urgent Matters launched a second learning network with six hospitals. The second learning network included a formal evaluation of the patient flow improvement strategies, including the facilitators and barriers to implementation, the time and expenses associated with implementation, and the impact of the strategies. Results of that evaluation are summarized in the report Improving Patient Flow and Reducing ED Crowding: Evaluation of Strategies from the Urgent Matters Learning Network II.16


a. Hospital Inpatient Quality Reporting Program. Overview available at

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Page last reviewed July 2018
Page originally created September 2012
Internet Citation: Section 1. The Need to Address Emergency Department Crowding. Content last reviewed July 2018. Agency for Healthcare Research and Quality, Rockville, MD.
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