Rasouli et al.

BMC Emergency Medicine (2019) 19:62

https://doi.org/10.1186/s12873-019-0275-9

RESEARCH ARTICLE Open Access

Challenges, consequences, and lessons for

way–outs to emergencies at hospitals: a
systematic review study
Hamid Reza Rasouli1*, Ali Aliakbar Esfahani2 and Mohsen Abbasi Farajzadeh2

Abstract
Background: Emergency Department (ED) overcrowding adversely affects patients’ health, accessibility, and quality
of healthcare systems for communities. Several studies have addressed this issue. This study aimed to conduct a
systematic review study concerning challenges, lessons and way outs of clinical emergencies at hospitals.
Methods: Original research articles on crowding of emergencies at hospitals published from 1st January 2007, and
1st August 2018 were utilized. Relevant studies from the PubMed and EMBASE databases were assessed using
suitable keywords. Two reviewers independently screened the titles, abstracts and the methodological validity of
the records using data extraction format before their inclusion in the final review. Discussions with the senior
faculty member were used to resolve any disagreements among the reviewers during the assessment phase.
Results: Out of the total 117 articles in the final record, we excluded 11 of them because of poor quality. Thus, this
systematic review synthesized the reports of 106 original articles. Overall 14, 55 and 29 of the reviewed refer to
causes, effects, and solutions of ED crowding, respectively. The review also included four articles on both causes
and effects and another four on causes and solutions. Multiple individual patients and healthcare system related
challenges, experiences and responses to crowding and its consequences are comprehensively synthesized.
Conclusion: ED overcrowding is a multi-facet issue which affects by patient-related factors and emergency service
delivery. Crowding of the EDs adversely affected individual patients, healthcare delivery systems and communities.
The identified issues concern organizational managers, leadership, and operational level actions to reduce crowding
and improve emergency healthcare outcomes efficiently.
Keywords: Emergency department, Emergency crowding, Overcrowding

Introduction Studies demonstrated increasing emergency healthcare

The requirement of emergency healthcare service for services use due to the raised accidental injuries. None-
people is an ongoing problem [1–5]. The ED must pro- theless, the potentials for emergency healthcare systems
vide emergency care to the large populations. Neverthe- have not been completely developed [3–5]. This situ-
less, the safe-networking of the emergency care added to ation generates the crowding and overcrowding of the
the complexity of the role because the ED should pro- EDs which in turn posed a reduction of quality health-
vide services to the users regardless of their insurance care services and results. Thus, crowding is a condition
and socioeconomic status [1, 2]. Furthermore, the ED when demand for emergency healthcare services exceeds
might be the only reference of health care services to from the available resources [3, 6].
people, particularly in rural areas [1, 2]. Overcrowding of the emergency healthcare services
has adverse results to the patients, the healthcare ser-
vices and the population [7, 8]. Delay in healthcare ser-
vices provided to patients can hurt the quality of the
* Correspondence: [email protected]
1
Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran,
emergency services and also their outcomes [9]. Over-
Iran crowding of the ED could also generate the adverse
Full list of author information is available at the end of the article

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Rasouli et al. BMC Emergency Medicine (2019) 19:62 Page 2 of 10

consequences of standards services preparation, which “Crowding occurs when the identified need for emergency
in turn might outcomes in patients way out the EDs services exceeds available resources for patient care in the
without obtaining the needed aids [7–9]. Despite the emergency department, hospital, or both” was used. Then,
contributions to the understanding of medical emergen- articles related to crowding in EDs published in English
cies [10, 11]. This systematic review aimed to assess the between January 1, 2007, and August 1, 2018, from the
causes and challenges of ED crowding, the experiences MEDLINE through PubMed and Embase electronic data-
of emergency patients, emergency care providers, and bases were searched. Search keywords and phrases utilized
healthcare systems, and the solutions to ED crowding were: ‘emergency’, ‘emergency medicine’, ‘pediatric emer-
and their consequences since 2007 globally. The out- gency medicine’, ‘emergency medical services’, ‘emergency
comes are expected to contribute inputs to decision- room’, ‘hospital emergency services’, ‘emergency health
makers to contextualize practical solutions to promote services’, ‘emergency department’, ‘emergency ward’, ‘EW’,
the quality of medical emergency services and to the sci- ‘ED’, “AND”, ‘crowding’, ‘overcrowded’, ‘crowded’ ‘over-
entific readership. crowding’, ‘divert’, ‘diversion’, ‘congestion’, ‘surged’, ‘sur-
ging’, ‘capacity’, ‘crises’, ‘crisis’, ‘occupancy’, ‘hospital bed
Materials and methods utilization’, ‘bed’, ‘utilization’, “OR”, “AND”, ‘effects’, ‘con-
Search strategy sequences’, ‘outcomes’,, affects’, ‘harm’, ‘impact’, ‘mortal-
In this study, the definition for “crowding” from the ity’, ‘challenges’, ‘causes’ ‘strategies’, ‘solutions’, ‘lessons’,
American College of Emergency Physicians which states ‘interventions’, ‘negative’.

Fig. 1 Study selection flowchart shows the database explorations, abstracts selected and the records included
Rasouli et al. BMC Emergency Medicine (2019) 19:62 Page 3 of 10

Data collection and quality assessment Causes of EDs crowding

Two reviewers (HRR AND MAF) independently screened Studies reported different factors affecting the EDs
the titles, abstracts and the methodological validity of the crowding. Table 1 presented the individual patients, in-
records using data extraction format before their inclusion puts (both human and material) and the service delivery
in the final review. Discussions with the senior faculty processes related factors that influenced crowding either
member (AAE) were used to resolve any disagreements directly or indirectly. Male gender, being young (< 18
among the reviewers during the assessment phase. A total years) [18], and old age [23, 24, 35] were a patient-
of 117 articles were eligible for the review (Fig. 1). The related factor associated with EDs crowding. The life-
studies using the standardized Critical Appraisal Skills style of the emergency patient such as alcoholism also
Programme (CASP) for the Cohort Studies [12], Qualitative led a frequent hospital visit and crowding [25].
Studies [13], and Systematic Reviews [14] were evaluated. The high number of emergency patients and the ser-
Moreover, the Joanna Briggs Institute Meta-Analysis of Sta- iousness of their conditions have hindered the timely ad-
tistics Assessment and Review Instrument for studies which missions of the emergency patients and led to EDs
employed other designs was utilized [15]. Finally, 11 studies overcrowding [3]. The increased waiting or boarding
with an eligibility evaluation score of fewer than 0.33 points time of patients in the ED, the delay in discharging of
(< 33%), the final review was based on 106 studies. the admitted patients [8, 26], and the high non-urgent
The methodology part of the eligible articles was fur- patient flow to the hospitals [17, 19] were other identi-
ther assessed using the R ‘wordcloud’ software package fied factors that contributed to the EDs crowding. Fur-
to gain insight into the keywords in the abstracts thermore, the delay in diagnostics and diagnostic test
[16]. We identified the focus of the studies and cate- result reports [19, 24, 27, 31] and the delay in initiating
gorized the articles into those related to causes, ef- treatment to emergency patients [32] were among the
fects, and solutions of crowding, and some form of emergency service delivery related factors associated
their combinations.

Table 1 Leading causes of EDs crowding

Results Patient-related factors [18, 20, 23–25]
Out of the total 106 eligible peer-reviewed original articles • Being a critically ill
included in the final review, 14, 55, and 29 of them were • Age (being child and aging)
on causes, effects, and solution of/to crowding of the ED,
• Male gender
respectively. The articles reported on causes and effects
were four [3, 17–19], and the remaining were on causes • Lifestyle such alcoholism
and solutions to crowding [9, 20–22] of/to crowding. Fur- Emergency service delivery related causes
ther assessment of the abstracts of the final articles using a) Emergency patient flow and emergency care related [3, 8, 17, 19, 22,
the R ‘wordcloud’ software package indicated some of the 26–30]
keywords and their frequencies (Fig. 2). • Delay in discharging admitted patients
• Severe emergency condition
• A high proportion of emergency patients
• Long waiting of emergency patients for diagnostic test results
b) Emergency department staff related causes [22, 25, 27, 28, 31–34]
• Wrong diagnosis
• Delay of consultants
• Delay of staff to provide emergency services
• Delay in transferring patients to inpatient ward
• Shortage of emergency care providers
c) Premises and materials of ED-related factors [9, 27]
• Shortage of beds for admitting emergency patients
Other hospital services delivery related causes [3, 19, 22, 27, 29, 31]
• Delay in laboratory and imaging investigations
• Delay in diagnostic test results/reports

Fig. 2 R ‘wordcloud’ of some of keywords in abstracts of the articles • The high number of patients in the waiting room of a hospital
eligible for final review and their frequencies • The reluctance of hospital staff to admit patients from ED
Rasouli et al. BMC Emergency Medicine (2019) 19:62 Page 4 of 10

with the increased the length of patients waiting time rate of patients [51]. The increased hospitalization of
that resulted in EDs crowding. The slow or delayed patients caused overuse of all facilities [64].
emergency patient admission process to the ED and in- The high workload caused prolonged service prepar-
patient wards [22, 33], and the prolonged laboratory and ation and clinical decision making and raised patients’
radiology testing influenced the crowding [22]. Shortage LOS [53, 54, 56, 60, 61, 63–78]. These conditions have
of emergency care staffs [22, 28] and hospital beds for adversely affected the quality of services and perform-
admission of emergency patients [9, 27], and the reluc- ance [17, 36, 40, 50, 61, 80, 81, 83].
tance of hospital staff to admit the emergency [29] were
identified contributors to the EDs crowding. Solutions to ED crowding
Medical emergencies and their negative consequences
Effects of EDs crowding were of concern and several studies identified or sug-
The outcomes of overcrowding of ED are multilevel in- gested different approaches (strategies, and tactics), and
cluding effect on patients’ health consequences, healthcare solutions to reduces or prevent ED crowding and related
delivery system and the communities. Table 2 shows the consequences. The approaches can be broadly catego-
mainly related outcomes of the ED overcrowding. ED rized into the organization or management level and op-
overcrowding caused delay treatment to patients and sub- eration level interventions (Table 3).
sequently increased risks of not being precisely examined
by the healthcare workers [19, 32, 36–40]. The patients Organization/management level solutions
through many walkouts may react to delay healthcare ser- Involving the executive leadership, implementing of
vices and the overcrowding [41]. These situations could hospital-wide coordinated strategies, strengthening
have an adverse effect of patients’ disease [50] and subse- evidence-based management and performance accountabil-
quently another consequences including re-admissions ity [90] were suggested solutions to reduce the LOS of pa-
[51, 62], hospitalizations [50, 52, 53], healthcare costs [54], tients at EDs. Other approaches for reducing the ED
patients’ satisfaction [42–45], medical malpractices, mor- crowding included implementing a coordinated patient
bidity [46–49], and patients’ mortality [50–61]. transfer networking system (RTNS) [91] and an independ-
The discharging of patients especially with high-risk ent capacity protocol [93, 94]. Furthermore, the application
clinical characteristics [51] and misleading the patients of lean principles/Six Sigma in service delivery [92], and
to other departments [18] have adversely impacted the pa- forecasting ED crowding [95] were strategies to shorten pa-
tients’ health consequences. These situations could increase tient discharging and boarding hours.
the time of accepting and transferring the outpatients [79]
and increase patient’s admission and re-admission rates Operational level solutions
[42, 61, 64, 89] consequently a reduced discharging Several studies recommended or identified interventions
involving the clinical staff, operational level strategies
Table 2 Adverse consequences of EDs crowding and tactics, service delivery processes, healthcare infra-
Adverse consequences on patients structure, and other services related factors that contrib-
• Increase delay to treatment, patients LWBS [19, 32, 36–40] and uted or would contribute to the solution of ED crowding
subsequently walkouts due to perceived ED LOS [41] and its negative aftermaths.
• Increase dissatisfaction [42–45] and medical malpractice [46–49]
• Increase adverse effect [50] and deaths [50–61]
• Increase readmissions [51, 62], hospitalization [50, 52, 53] and costs for a. Staffing the ED and motivating the staffs:
healthcare [54] Introducing the pay for performance mechanism
Adverse consequences on healthcare delivery system [96] and assigning ED residents [97] can contribute
• Increase workload [63], delay service provision/decision making and to the reduction of LOS of patients. Thus, the
increased ED LOS [53, 54, 56, 60, 61, 63–78] allocation of residents at the ED not only reduces
• Increase delay to management of outpatients [79] and overuse of ED the waiting time but also reduces the number of
facilities [64]
• Decrease efficiency, and increase costs of healthcare [17, 36, 40, 50, 61, patients LWBS [98].
80, 81] b. Operational level strategies and tactics: Studies
• Decrease consideration for infection prevention and control measures [82] identified several operational-level means to reduce
• Decrease time and precise to examination patients’ conditions [71],
compliance to standardization of healthcare [52] and quality of or prevent ED crowding. The methods included
healthcare [39, 42, 63, 83–87] evidence-based patient admission [21], the applica-
• Discharging of patients with high-risk clinical features [51] and divert- tion of a Discrete Event Simulation (DES) model [22],
ing of patients to proper facilities [18]
• Increase patients readmission rate [42] and admission rate to hospital improving the emergency patient flow coordination
wards [64] leadership [101], introducing a Stat Lab within the
Decrease discharging rate of patients [37, 51, 57, 59, 66, 79, 88] and ED [105], and implementing specific hospital-level
admission of patients [89]
action plans (Code Help Regulation) [106]. The use
Rasouli et al. BMC Emergency Medicine (2019) 19:62 Page 5 of 10

Table 3 Solutions of EDs crowding and increase the four-hour performance without comprom-
Organization or management level solutions ising the quality of care [103]. Following the four-hour-rule
• Executive leadership involvement, hospital-wide coordinated strategies, in deciding for admitting or discharging of patients also re-
data-driven management, and performance accountability [90] duces patient death [104]. Furthermore, properly utilizing
• Implementing emergency patient transfer network system (RTNS) [91] the unused capacity (smoothing strategy) [100], and using
• Implementing Lean/Six Sigma Method [92] the capacity alert escalation calls [20] contribute to the re-
duction of the ED crowding by lowering ED bed occupancy
• Implementing an independent capacity protocol [93, 94]
rates. Assessing the patients in the waiting room was a feas-
• Forecasting ED crowding [95]
ible approach to reduce the ED crowding [102]. Besides,
Operational level solutions the use a dashboard provides real-time information which
a. Staffing and motivation leads to actions towards preventing crowding [107].
• Pay for performance [96]
• Staffing ED with qualified professionals [97, 98] c. Service delivery process: Some interventions
focused on emergency service delivery can reduce
b. Operational level strategies and tactics
crowding. For example, initiating an acute care
• Developing evidence-based admission criteria [21]
emergency surgery service, improving the ED
• Implementing Electronic Blockage System (EBS) [99] patient flow and introducing an efficient patient
• Implementing smoothing strategy [100] discharging process reduce the ED bed occupancy
• Using capacity alert escalation calls [20] and LOS [108, 111, 114]. The high-turnover utility
• Applying Discrete Event Simulation (DES) model [22] bed management can also decrease ambulance di-
version hours and LOS of patients [112]. The prac-
• Improving leadership of ED [101]
tice of triage by physicians reduce the patients
• Implementing contingency strategy [102]
LWBS in the EDs [110]. Other interventions which
• Using management-support multimodal hospital-wide interventions [103] contribute to the reduction of crowding included
• Implementing four-hour-rule for emergency care [104] whole week emergency service delivery [109] and
• Introducing of Stat Lab [105] implementing Timely Quality Care [113].
• Implementing Code Help Regulation [106] d. Other services: Improving other services such as
enhancing primary care [21, 115], optimizing
• Using a dashboard to provide real-time information about crowding [107]
translation services concerning patients’ issues [21]
c. Service delivery process
and an engagement on specialists in the outpatient
• Acute care emergency surgery service provision [108] environment [116, 117] contribute to the reduction
• Whole week emergency service delivery [109] of ED LOS and crowding.
• Implementing triage by physicians [110] e. Premises: The high emergency patient flow forced
• Introducing efficient patient discharging process [111] the healthcare delivery system to address related
issues. Expanding or opening additional EDs were
• High-turnover utility bed management [112]
suggested to reduce patients LWBS and boarding
• Implementing Timely Quality Care [113]
hours [116, 117]. Others followed hallway emergency
• Implementing an improved ED patient flow [114] bed policy [9] and increasing hospital bed capacity
d. Other services [118] to reduce waiting time and ED crowding.
• Enhanced primary care [21, 115]
• Optimizing translation services [21] Discussion
Patients in the extreme the age categories (being a child
e. Premises
and the elderly) [18, 23–25, 35], might have contributed
• Expanding or opening additional EDs [116, 117]
to the crowding due to reduced physical mobility and
• Hallway emergency bed [9] the involvement of their relatives and the different emer-
• Increasing hospital bed capacity [118] gency care expertise in their care. Among other personal
factors, alcoholic patients who present to the ED [25]
of Electronic Blockage System (EBS) (a form of might also have limited mobility or might be unable to
triage system) contributed to the reduction of the provide self-care. Being a male patient was also associ-
ED crowding and the facilitation of patients ated with frequent ED visits, while the exact relationship
admissions [99]. was not clear [18]. While a recent systematic review did
not report concerning the relationship between Individ-
The application of management-support multimodal ual characteristics and crowding [119], our systematic
hospital-wide interventions decreases the ED occupancy review revealed an association between age and ED
Rasouli et al. BMC Emergency Medicine (2019) 19:62 Page 6 of 10

crowding. Nevertheless, being male, arriving of emer- negatively affected patients’ mortality, quality of health-
gency patients during the weekends, and being adult care, and costs of services [10].
non-trauma patients were reported to be linked with Our results demonstrated that ED overcrowding nega-
short LOS. tively effects on patients’ health, healthcare delivery ser-
The seriousness of the emergency condition, the high vices and the communities [42–49, 52–61, 64, 79, 89].
flow of emergency patients, and the involvement of the The high workload caused prolonged healthcare services
different actors (relatives and health professionals) affect and clinical decision making and raised patients’ LOS
the service delivery process [3, 26–29, 120]. These con- [53, 54, 56, 60, 61, 63–78]. Several emergency healthcare
ditions are more likely to cause a delay in emergency systems associated outcomes evaluated by Morley et al.
care provision [33], admitting and discharging of pa- study (2018) for chiefly they concentrated on inpatient
tients [26], and an increase in the waiting time of pa- LOS and ED LOS [11].
tients [120], in which all of them can lead to increased The involvement of the executive leaders, the use of
ED crowding. The high flow of in and out of the emer- hospital-wide coordinated approaches, and evidence-based
gency patients including the inpatient boarding [10] and management and performance accountability were some
the presence of urgent and complex emergency condi- of the strategies implemented to reduce ED crowding and
tions of the patients usually lead to crowding of the ED its consequences [90]. The use of a coordinated emergency
[120]. The prolonged LOS in EDs related to some causes patient transfer network system [91], and an independent
[21] and the large volume of emergency patients flow to capacity protocol [93, 94] were as strategies for reducing
the ED are a common reason for crowding. ED LOS of patients. Furthermore, the lean principles/Six
Several healthcare providers related factor including Sigma Method in service delivery [92] and forecasting of
wrong diagnosis, delay in consultants to see emergency ED crowding [95] believed to shorten patient discharging
patients, delay in services provision and transferring of and boarding hours. Another systematic review study also
patients to inpatient wards, and a shortage of emergency identified leadership program/support and alternative ad-
healthcare providers [22, 25, 27, 28, 31–34] contributed mission policies as solutions to crowding [11].
to the ED crowding. Other previous systematic reviews Several specific technical (front-line) level tools or so-
also identified inadequate staffing including the shortage lutions have been identified. The staffing of the ED with
of emergency care nursing staff and delays in clinical de- qualified professionals [98] and the use of motivational
cisions as causes of ED crowding [10, 11]. mechanisms such as pay for performance [96] contrib-
The inadequacy of beds at the ED for admitting pa- uted to the alleviation of ED crowding. Developing and
tients was health infrastructure related causes of crowd- using evidence-based admission criteria [21], implement-
ing [9, 27]. Similarly, other systematic reviews also ing Electronic Blockage System [99] and smoothing
identified the shortage of beds to be associated with ED strategy [100], using capacity alert escalation calls [20]
crowding [10, 11]. The high flow of emergency patients and applying Discrete Event Simulation (DES) model
to the ED who may require admissions and the limited [22] were also the tactics applied to facilitate emergency
number of beds in the ED leads to crowding and poor service delivery and reduce crowding. Improving leader-
healthcare outcomes. ship of the ED [101], evaluating emergency patients in
The delay in laboratory investigations, diagnostic im- the waiting room as a contingency strategy [102], and
aging and in reporting diagnostic test results contribute using management-support multimodal hospital-wide
to ED crowding [24, 27]. The shortage of materials and interventions [103] were other reported tactics. Further-
other resources can lead to delay in laboratory test results more, implementing four-hour-rule for emergency care
[31]. The high number of emergency patients [19], the re- [104], introducing Stat Lab [105], implementing Code
luctance of the hospital staff to admit emergency patients Help Regulation [106] and Using a dashboard to provide
[29] and the inadequate number of emergency patient ad- real-time information about crowding [107] were pro-
missions [10, 11] were also reasons for crowding. posed operational tactics to the reduce ED crowding and
The results showed ED overcrowding related to delay related consequences.
treatment and increased risks not being seen for patients Studies identified several technical level (or front-line)
[19, 32, 36–40]. These conditions have an adverse effect measures or solutions targeting the alleviation of ED
of their disease [50], readmissions [51, 62], hospitaliza- crowding. Staffing the ED with qualified professionals
tions [50, 52, 53], healthcare costs [54], patients’ satisfac- [98] and pay for performance [96] were among others.
tion [42–45]. In a systematic review by Morley et al. Other tactics which aimed to to facilitate emergency ser-
(2018) showed prolonged patient evaluation and prepar- vice delivery and reduce crowding included: developing
ation of care could adversely affect death rate, medical and using evidence-based admission criteria [21], imple-
malpractice and patient satisfaction [11]. Also, in another menting Electronic Blockage System [99], and smoothing
systematic review study (2008) showed EDs overcrowding strategy [100], using capacity alert escalation calls [20]
Rasouli et al. BMC Emergency Medicine (2019) 19:62 Page 7 of 10

and applying Discrete Event Simulation (DES) model bed [9] and increasing hospital bed capacity [118] as a solu-
[22]. Improving leadership of the ED [101], evaluating tion to prevent crowding. Some studies showed reporting
emergency patients in the waiting room as a contin- of ED utilization to a pediatric specialist was correlated with
gency strategy [102], and using management-support a cultural and method development to preferentially man-
multimodal hospital-wide interventions [103] were other age patients with essential matters in the office [119, 120].
reported tactics. Furthermore, implementing four-hour-
rule for emergency care [104], introducing Stat Lab [105], Strengths and limitation
implementing Code Help Regulation [106] and Using a This study attempted to characterize the details of the
dashboard to provide real-time information about crowd- challenges, emergency patients and emergency clinical
ing [107] were proposed operational level tactics to the re- staff reactions to clinical emergencies, and the strategies
duce ED crowding and related consequences. and tactics followed by healthcare service organizations
Operational interventions targeting the service delivery and front-line staff to tackle ED crowding and related is-
processes were also identified. Initiating an acute care sues. Comprehensive keywords and terms to cover all
emergency surgery service, improving ED patient flow relevant published studies on ED crowding from the
and introducing an efficient patient discharging process PubMed and Embase databases were utilized. The qual-
could reduce the ED bed occupancy rate and LOS [108, ities of the studies were evaluated by appropriate check-
111, 114]. The high-turnover utility bed management [112], lists and excluded those with low-level quality. However,
the practice of triage by physicians [110], whole week emer- the systematic review study was limited to studies pub-
gency service delivery [109], and implementing Timely lished only in the English language. The included ori-
Quality Care [113] contributed to the improvements in ginal studies did not utilize a unique definition for EDs
service delivery and reduction of crowding. A recent sys- crowding measurement, which led to the inclusion of all
tematic review also identified different crowding measure, ED crowding-related information in the synthesis.
social interventions, fast track, ED nurse flow coordinator
as operational level solutions to ED crowding [11]. Conclusions
Initiating an acute care emergency surgery service, ED overcrowding is a multi-facet issue which affects by
improving ED patient flow, and introducing an efficient patient-related factors and emergency service delivery.
patient discharging process [108, 111, 114] were recom- Crowding of the EDs adversely affected individual pa-
mended interventions targeting improvement in service tients, healthcare delivery systems and communities. The
delivery processes and reduction in ED bed occupancy identified issues concern organizational managers, leader-
rate and LOS. High-turnover utility bed management ship, and operational level actions to reduce crowding and
[112], practicing triage by physicians [110], whole week improve emergency healthcare outcomes efficiently. This
emergency service delivery [109], and implementing systematic review study showed the importance of the in-
Timely Quality Care [113] were also frontline interven- tegrated response to emergencies and emergency related
tions that contribute to improved service delivery and overcrowding and consequences to better address the
reduced crowding. A recent systematic review also iden- healthcare needs of emergency patients and effectiveness
tified different crowding measure, social interventions, of healthcare service delivery facilities. Also, multiple
fast track, and ED nurse flow coordinator as operational health service organization and operational level responses
level solutions to ED crowding [11]. to emergency-related crowding and their consequences
The emergency care service provision should be ac- were identified.
commodating. Some studies suggested enhancing pri-
Abbreviations
mary care as a means of reducing the ED crowding [21, CASP: Critical Appraisal Skills Programme; ED: Emergency Department;
115], while another study proposed the optimization of LOS: Length of Stay; LWBS: Left without Being Seen; MeSH: Medical Subject
translation services to reduce crowding [21]. Others Headings
recommended premises related interventions such as Acknowledgements
expanding or opening an additional ED [116, 117], hall- Not applicable
way emergency bed [9] and increasing hospital bed cap-
Authors’ contributions
acity [118] as a solution to prevent crowding. All the authors (HRR, AAE, and MAF) have contributed to the construction of
The emergency healthcare service provision should meet the concepts, data gathering, data analysis, preparation of the final
the needs of the patients. Some studies suggested enhan- manuscript and all authors have read and approved the manuscript.
cing primary care as a means of reducing ED crowding [21, Funding
115], while another study proposed the optimization of Not applicable
translation services to reduce crowding [21]. Other sugges-
Availability of data and materials
tions were premises related interventions such as expanding The datasets used and/or analyzed during the current study are available
or opening additional ED [116, 117], hallway emergency from the corresponding author on reasonable request.
Rasouli et al. BMC Emergency Medicine (2019) 19:62 Page 8 of 10

Ethics approval and consent to participate 20. Khanna S, Boyle J, Zeitz K. Using capacity alert calls to reduce overcrowding
The research protocol was approved by the review committee of the in a major public hospital. Aust Health Rev. 2014;38(3):318–24.
Baqiyatallah University of Medical Sciences. It did not involve data collection 21. Mansbach JM, Clark S, Barcega BR, Haddad H, Camargo CA Jr. Factors associated
at individual level or human subjects. with longer emergency department length of stay for children with bronchiolitis :
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22. Paul JA, Lin L. Models for improving patient throughput and waiting at
Consent for publication
hospital emergency departments. J Emerg Med. 2012;43(6):1119–26.
Not applicable
23. Knapman M, Bonner A. Overcrowding in medium-volume emergency
departments: effects of aged patients in emergency departments on wait
Competing interests times for non-emergent triage-level patients. Int J Nurs Pract. 2010;16(3):310–7.
The authors declare that they have no competing interests. 24. Vegting IL, Alam N, Ghanes K, Jouini O, Mulder F, Vreeburg M, et al. What
are we waiting for? Factors influencing completion times in an academic
Author details and peripheral emergency department. Neth J Med. 2015;73(7):331–40.
1
Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, 25. Verelst S, Pierloot S, Desruelles D, Gillet JB, Bergs J. Short-term unscheduled
Iran. 2Marine Medicine Research Center, Baqiyatallah University of Medical return visits of adult patients to the emergency department. J Emerg Med.
Sciences, Tehran, Iran. 2014;47(2):131–9.
26. Mustafa F, Gilligan P, Obu D, O'Kelly P, O'Hea E, Lloyd C, et al. 'Delayed
Received: 8 January 2019 Accepted: 9 October 2019 discharges and boarders': a 2-year study of the relationship between
patients experiencing delayed discharges from an acute hospital and
boarding of admitted patients in a crowded ED. Emerg Med J. 2016;
33(9):636–40.
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