Urban emergency department overcrowding: defining the problem and eliminating misconceptions.

STUDY OBJECTIVE To develop an operational definition and a parsimonious list of postulated determinants for urban emergency department (ED) overcrowding. METHODS A panel was formed from clinical and administrative experts in pre-hospital, ED and hospital domains. Key studies and reports were reviewed in advance by panel members, an experienced health services researcher facilitated the panel's discussions, and a formal content analysis of audiotaped recordings was conducted. RESULTS The panel considered community, patient, ED and hospital determinants of overcrowding. Of 46 factors postulated in the literature, 21 were not retained by the experts as potentially important determinants of overcrowding. Factors not retained included access to primary care services and seasonal influenza outbreaks. Key determinants retained included admitted patients awaiting beds and patient characteristics. Ambulance diversion was considered to be an appropriate operational definition and proxy measure of ED overcrowding. CONCLUSION These results help to clarify the conceptual framework around ED overcrowding, and may provide a guide for future research. The relative importance of the determinants must be assessed by prospective studies.

[1]  A. Kellermann,et al.  Critical decision making: managing the emergency department in an overcrowded hospital. , 1991, Annals of emergency medicine.

[2]  D. Morgan.  Successful Focus Groups: Advancing the State of the Art , 1993 .

[3]  G Dickinson,et al.  Emergency department overcrowding. , 1989, CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne.

[4]  E. Gallagher,et al.  The etiology of medical gridlock: causes of emergency department overcrowding in New York City. , 1990, The Journal of emergency medicine.

[5]  V. Goel,et al.  Factors related to emergency department use: results from the Ontario Health Survey 1990. , 1994, Annals of emergency medicine.

[6]  J. Richards,et al.  Overcrowding in the nation's emergency departments: complex causes and disturbing effects. , 2000, Annals of emergency medicine.

[7]  D A Redelmeier,et al.  Emergency department overcrowding following systematic hospital restructuring: trends at twenty hospitals over ten years. , 2001, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[8]  Thorpe Ke.  The current hospital crisis in New York City and policy options for resolving it. , 1990 .

[9]  Americancollegeofemergencyphy.  Hospital and emergency department overcrowding. , 1990, Annals of emergency medicine.

[10]  M. Patton,et al.  Qualitative evaluation and research methods , 1992 .

[11]  I. Feferman,et al.  How we solved the overcrowding problem in our emergency department. , 1989, CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne.

[12]  R. Zeller,et al.  Focus Group Research on Sensitive Topics: Setting the Agenda without Setting the Agenda , 1993 .

[13]  Raynald Pineault,et al.  Assessing Quebec's Multi-Component Program to Reduce Emergency Room Overcrowding , 1992 .

[14]  S. Ziebland,et al.  Analysing qualitative data , 2000, BMJ : British Medical Journal.

[15]  N. Egan.  Managing a bed crisis. , 1999, Journal of accident & emergency medicine.

[16]  E. T. Boie,et al.  Do parents want to be present during invasive procedures performed on their children in the emergency department? A survey of 400 parents. , 1999, Annals of emergency medicine.

[17]  J. Richards,et al.  Survey of directors of emergency departments in California on overcrowding. , 2000, The Western journal of medicine.

[18]  R. Kravitz,et al.  Frequent overcrowding in U.S. emergency departments. , 2001, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[19]  L. McCaig,et al.  National Hospital Ambulatory Medical Care Survey: 1998 outpatient department summary. , 2000, Advance data.

[20]  P. Krochmal,et al.  Increased health care costs associated with ED overcrowding. , 1994, The American journal of emergency medicine.

[21]  L. McCaig,et al.  National Hospital Ambulatory Medical Care Survey: 1992 emergency department summary. , 1994, Advance data.

[22]  S. M. Wang,et al.  ED overcrowding in Taiwan: facts and strategies. , 1999, The American journal of emergency medicine.

[23]  J. Geiderman,et al.  D IVERSION OF ALS A MBULANCES : C HARACTERISTICS , C AUSES, AND E FFECTS IN A L ARGE U RBAN S YSTEM , 2001, Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors.

[24]  K. Grumbach,et al.  Primary care and public emergency department overcrowding. , 1993, American journal of public health.

[25]  H G Garrison,et al.  Ambulance diversion. Standards and Clinical Practices Committee, National Association of EMS Physicians. , 1997, Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors.

[26]  Ò. Miró,et al.  Decreased health care quality associated with emergency department overcrowding. , 1999, European journal of emergency medicine : official journal of the European Society for Emergency Medicine.

[27]  D. Redelmeier,et al.  No place to unload: a preliminary analysis of the prevalence, risk factors, and consequences of ambulance diversion. , 1994, Annals of emergency medicine.

[28]  Sue Ziebland,et al.  Analysing qualitative data , 2000, BMJ : British Medical Journal.

[29]  K. Thorpe.  The current hospital crisis in New York City and policy options for resolving it. , 1990, New York state journal of medicine.

[30]  A. Kellermann,et al.  Emergency departments and crowding in United States teaching hospitals. , 1991, Annals of emergency medicine.