Marina Sartini 1,2,*, Alessio Carbone 1, Alice Demartini 1, Luana Giribone 1, Martino Oliva 1, Anna Maria Spagnolo 1,2, Paolo Cremonesi 3, Francesco Canale 4, Maria Luisa Cristina 1,2
Abstract
Overcrowding in Emergency Departments (EDs) is a phenomenon that is now widespread globally and causes a significant negative impact that goes on to affect the entire hospital. This contributes to a number of consequences that can affect both the number of resources available and the quality of care. Overcrowding is due to a number of factors that in most cases lead to an increase in the number of people within the ED, an increase in mortality and morbidity, and a decrease in the ability to provide critical services in a timely manner to patients suffering from medical emergencies. This phenomenon results in the Emergency Department reaching, and in some cases exceeding, its optimal capacity. In this review, the main causes and consequences involving this phenomenon were collected, including the effect caused by the SARS-CoV-2 virus in recent years. Finally, special attention was paid to the main operational strategies that have been developed over the years, strategies that can be applied both at the ED level (microlevel strategies) and at the hospital level (macrolevel strategies).
Keywords: overcrowding, emergency department, hospital admission
1. Introduction
The Emergency Department (ED) is one of the most crowded hospital units, where many patients with various medical conditions, including high-risk patients, are admitted [1]. The main purpose of the ED is to treat emergency and urgent cases that need immediate assistance through a rapid diagnosis and the administration of a medical or surgical treatment in a very short time. It has now been established that the malfunctioning of health services in the community leads to improper access to the ED, especially in the geriatric and pediatric age groups [1,2,3]. ED’s crowding, sometimes referred to as overcrowding, has been identified as a problem for a timely and efficient assistance since the 1980s [4].
Overcrowding can be defined as a situation in which the performance of the emergency department is compromised, mainly due to the excessive number of patients waiting for consultation, diagnosis, treatment, transfer, or discharge [2,5]; overcrowding is characterized by an imbalance between supply and demand [2].
Although many factors contribute to overcrowding, the latter depends essentially on three factors: the incoming volume of patients (input), the time to process and treat patients (throughput), and the volume of patients leaving the ED (output) [6].
Among the different factors, patient boarding was found to be one of the most significant [7]. Boarding is the practice of keeping patients admitted to the ED for prolonged periods due to inadequate capacity of inpatient wards [7,8]. Boarding, and overcrowding in general, has negative effects on patient care, mortality, morbidity, patient satisfaction, and quality of care [4,9,10]. These also contribute to a longer length of stay (LOS) in the ED, an increased rate of patients leaving the ED without being seen (LWBS, left without being seen), and increased medical errors [11,12,13].
ED overcrowding has turned into a serious health problem, as the number of EDs is decreasing, while the number of patients requiring emergency services is increasing [11,13]. It has been reported in the literature that overcrowding occurs most often in EDs with an annual volume of over 40,000 visits [11,14].
An accurate measurement of crowding in the ED and an evidence-based understanding of its impact are essential prerequisites before attempting to find solutions [6]. Although there are various scores for estimating the different degrees of overcrowding, to date, there is still no gold standard for measuring this phenomenon [4,15]. A review in the literature suggests that overcrowding is defined by the following three estimation indices: National Emergency Department Overcrowding Score (NEDOCS), Community Emergency Department Overcrowding Score (CEDOCS), and Severely-overcrowded-Overcrowded and Not-overcrowded Estimation Tool (SONET). The most frequently used score is the NEDOCS, developed by Weiss and colleagues [15]; NEDOCS converts a series of variables into a score, which is related to the degree of overcrowding perceived by the professionals performing their tasks at that moment. The scale has a range between 0 and 200 points, where a rating of 101 or more indicates a condition of overcrowding [16].
Finally, among the measurement systems that can be evaluated to estimate overcrowding, we also have ED occupancy, ED length of stay, ED volume, ED boarding time, number of boarders, waiting room number, and the Emergency Department Work Index (EDWIN) score. So, in order to develop efficient solutions to overcrowding, it is essential not only to understand its various causes and effects but also to estimate its actual impact on the health care system [4].
This paper aims to make an additional contribution to the understanding of overcrowding in the ED by providing an analytical overview of the causes, effects, and solutions to the problem; to our knowledge, there are not many papers that deal with the topic with this organic vision.
Reference:
