healthcare

Review
Overcrowding in Emergency Department: Causes,
Consequences, and Solutions—A Narrative Review
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 and Maria Luisa Cristina 1,2

1 Department of Health Sciences, University of Genova, Via Pastore 1, 16132 Genoa, Italy
2 Operating Unit (S.S.D. U.O.) Hospital Hygiene, Galliera Hospital, Mura delle Cappuccine 14,
16128 Genoa, Italy
3 Emergency Department, Galliera Hospital, Mura delle Cappuccine 14, 16128 Genoa, Italy
4 Medical Service Management, Galliera Hospital, Mura delle Cappuccine 14, 16128 Genoa, Italy
* Correspondence: [email protected]; Tel.: +39-010-353-8479

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
Citation: Sartini, M.; Carbone, A.; the years, strategies that can be applied both at the ED level (microlevel strategies) and at the hospital
Demartini, A.; Giribone, L.; Oliva, M.; level (macrolevel strategies).
Spagnolo, A.M.; Cremonesi, P.;
Canale, F.; Cristina, M.L. Keywords: overcrowding; emergency department; hospital admission
Overcrowding in Emergency
Department: Causes, Consequences,
and Solutions—A Narrative Review.
Healthcare 2022, 10, 1625. https:// 1. Introduction
doi.org/10.3390/healthcare10091625
The Emergency Department (ED) is one of the most crowded hospital units, where
Academic Editor: César Leal-Costa many patients with various medical conditions, including high-risk patients, are admit-
Received: 14 July 2022
ted [1]. The main purpose of the ED is to treat emergency and urgent cases that need
Accepted: 23 August 2022
immediate assistance through a rapid diagnosis and the administration of a medical or
Published: 25 August 2022
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
Publisher’s Note: MDPI stays neutral
geriatric and pediatric age groups [1–3]. ED’s crowding, sometimes referred to as over-
with regard to jurisdictional claims in
crowding, has been identified as a problem for a timely and efficient assistance since the
published maps and institutional affil-
1980s [4].
iations.
Overcrowding can be defined as a situation in which the performance of the emer-
gency department is compromised, mainly due to the excessive number of patients waiting
for consultation, diagnosis, treatment, transfer, or discharge [2,5]; overcrowding is charac-
Copyright: © 2022 by the authors.
terized by an imbalance between supply and demand [2].
Licensee MDPI, Basel, Switzerland. Although many factors contribute to overcrowding, the latter depends essentially on
This article is an open access article three factors: the incoming volume of patients (input), the time to process and treat patients
distributed under the terms and (throughput), and the volume of patients leaving the ED (output) [6].
conditions of the Creative Commons Among the different factors, patient boarding was found to be one of the most signif-
Attribution (CC BY) license (https:// icant [7]. Boarding is the practice of keeping patients admitted to the ED for prolonged
creativecommons.org/licenses/by/ periods due to inadequate capacity of inpatient wards [7,8]. Boarding, and overcrowding
4.0/). in general, has negative effects on patient care, mortality, morbidity, patient satisfaction,

Healthcare 2022, 10, 1625. https://doi.org/10.3390/healthcare10091625 https://www.mdpi.com/journal/healthcare

Healthcare 2022, 10, 1625 2 of 13

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 [11–13].
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 understand-
ing 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 liter-
ature 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 overcrowd-
ing, 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 over-
crowding 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.

2. Materials and Methods

In this narrative review article, a comprehensive search on PubMed.gov, Scopus, ISI
Web of Science, Science Direct, and Google Scholar using as keywords “Overcrowding”,
“Emergency Department”, “Hospital admission”, “Length of Stay”, “Waiting time”, and
“inpatient boarding” up to June 2022 using Medical Subject Headings (MeSH) terms as
vocabulary was performed. Inclusion criteria were: (1) research articles with quantitative
details and information on the relationship between the causes that lead to overcrowding
in Emergency Departments and the consequences that this phenomenon entails; (2) articles
describing possible strategies already adopted or adoptable in the future to address the
effect that overcrowding has on the Emergency Department were considered. Exclusion
criteria were articles not directly pertinent to the query string or articles not containing suf-
ficient information on the relationship between overcrowding and Emergency Departments
(Table 1).
Two authors were involved during the screening of the literature. Articles were firstly
selected based on title and abstract. The full text of relevant research was then acquired
and assessed. Each reference of the selected articles was checked in order not to miss any
relevant article. The authors independently read all the papers. A complete consensus was
achieved through discussion for the texts included in this study.
Healthcare 2022, 10, 1625 3 of 13

Table 1. Search strategy.

Search Strategy Details

(Emergency Department [MeSH Terms]) AND (Overcrowding) OR
Search string
(Crowding)(Overcrowding) AND (ED) OR (Emergency Department)
Databases PubMed/MEDLINE, Scopus, Cochrane, and Google Scholar
(1) research articles with quantitative details and information on the
relationship between the causes that lead to overcrowding in
Emergency Departments and the consequences that this phenomenon
Inclusion criteria entails; (2) articles describing possible strategies already adopted or
adoptable in the future to address the effect that overcrowding has on
the Emergency Department were considered;
(3) all kinds of study designs and reviews
Items not directly pertinent to the query string and articles not
containing sufficient information on the relationship between
Exclusion criteria Overcrowding and Emergency Department
Study design: editorial, commentaries, expert opinions,
letters to editor, and abstracts
Time filter None (from inception)
Language filter Only Italian and English articles

3. Results
After removal of duplicate items, the resulting list comprised 113 nonredundant
articles, and 61 were finally considered in our narrative review.

3.1. Causes of ED Overcrowding

As anticipated, the problem of overcrowding in EDs can be due to multiple factors,
which may be represented by the input–throughput–output model (Table 2). Overcrowding
is a multifactorial and complex phenomenon; these different factors are independent from
one another but are closely connected and influenced by additional factors [10,17,18].

Table 2. Main causes of overcrowding.

Factors Causes
Presentations with more urgent and complex care needs
• Emergencies
Increase in presentations by the elderly
High volume of low-acuity presentations (LAPs)
Access to primary care
• The poor and uninsured who lack primary care
Input Limited access to diagnostic services in community
due to the volume of patients arriving and waiting to be seen • The malfunctioning of health care services in the community
Inappropriate use of emergency services
• Unnecessary visits
• “Frequent flyer” patients
• Nonurgent visits
• The majority of ED incomings resulted from
self-referral process
The number of escorts accompanying a patient
Healthcare 2022, 10, 1625 4 of 13

Table 2. Cont.

Factors Causes
ED nursing staff shortages
Low staffing and resource levels
Presence of junior medical staff in ED
Throughput Delays in receiving test results and delayed disposition decisions
due to the time to process and/or treat patients Number of tests (blood test and urinalysis) required to be
performed per patient
Too long a consultation time
Patient degree of gravity
Bed availability (both in the ED and in the hospital)
Boarding
Output Exit block
due to the volume of patients leaving the ED Lack of available hospital beds
Inefficient planning of discharging patients
An increase in closures of a significant number of EDs
Time of the year
• Influenza season
Others
• Seasonal illness
Weekend, holiday periods
COVID-19

3.1.1. Input Factors

Input factors are those which lead to increased admissions in the ED [10,19]. These
include the development of new or unsatisfied care needs in appropriate areas of com-
munity care, the progressive aging of the population, the increasing number of complex
patients, the introduction of new diagnostic and treatment technologies, and the increase
in admissions for diseases related to seasonal epidemiology (e.g., flu epidemics and heat
waves) or related to time of year/week. Input factors cannot be controlled by the ED [10,20].
It has been observed that the number of escorts has a negative impact on the workflow
in the ED. Although they do not play an active role in the process, they may unintentionally
annoy the staff and consequently increase the workload and pressure in the ED. For this
reason, some hospitals in Israel have reduced the number of escorts per patient to one [18].
Another important input factor is avoidable accesses, which can be considered “con-
ditions susceptible of ambulatory treatment”, including major chronic diseases, double
accesses related to inappropriate performance of the territorial emergency network, more
generally repeated accesses (e.g., frequent flyers) as well as all improper accesses related to
territorial organizational patterns (e.g., schedules) and patient habits [20,21].
Some studies have found a positive relation between ED overcrowding and patient
admission rates, and this effect further increases for patients classified as less severe. These
findings suggest that ED overcrowding could be causing multiple problems, such as
unnecessary consumption of medical resources due to unnecessary hospitalizations [22,23].

3.1.2. Throughput Factors

Throughput factors are those internal to the ED itself and which affect the time from
patient admission to discharge, hospitalization, or transfer (LOS) [10].
Among the throughput factors, the one that most influences a patient’s LOS is the
need for specialistic consultations and/or additional instrumental diagnostic investigations,
procedures that are increasingly necessary both because of the increasing average age of pa-
tients and comorbidities and to ensure appropriate hospitalizations and safe discharges [20].
Prolonged inpatient times may be the result of overcrowding, delayed radiological and
laboratory test results, delayed and inappropriate consultations, and inadequate number of
inpatient beds [21].
Healthcare 2022, 10, 1625 5 of 13

ED productivity is also affected by the work efficiency of hospital staff. It is important

that the demand for assistance and the actual working capacity are balanced so that it can
be ensured that the flow goes on properly, especially under emergency conditions [20].
Anything that compromises the flow of patients through the ED can lead to overcrowd-
ing [19]; if a resource (e.g., medical staff, consultant, diagnostic service, or bed slot) has a
demand that exceeds its capacity, there will be a blockage in the system; therefore, the flow
will be regular if available resources balance the demand in all the stages of the path [6,20].

3.1.3. Output Factors

Output factors can be summarized by the failure to transfer patients out of the ED
following all necessary treatment. Among these factors are the availability of beds and the
delay in transporting patients to free up space in the ED, thus leading patients to remain
waiting both to reach the appropriate department and for their eventual discharge. So,
it is clear just how large the impact is, which these factors exert on overcrowding, given
that they burden not only the level of space and bed availability, but also other health care
resources [10].
As mentioned earlier, bed availability and inability to receive adequate home care
are among the most important factors causing overcrowding. These not only affect EDs
locally but also globally, and this also determines other phenomena of exit block and
boarding [10,20].
Exit block is a phenomenon that is likely to occur when patients in the ED are unable
to access beds in a reasonable time. The result is an increase in overcrowding, since in
these cases the hospital, and especially the ED, has already reached maximum limits of
admission, and new arrivals will lead to their waiting longer than the necessary time.
Exit block leads to important consequences, both in terms of patient health, increased
waiting time, boarding, and quality of care. Many studies have focused on the negative
impact of exit block, not only on low-risk patients but also on those in need of immediate
surgery, for example, in emergency situations. Finally, it has been observed how this
phenomenon and overcrowding can affect a patient’s choice to leave the ED, without first
undergoing a proper medical examination, potentially leading to a worse outcome [10].
A lack of beds can lead to the practice of retaining patients within the ED thus leading
to the phenomenon of boarding, which is directly dependent on the exit block. Indeed,
like the latter, boarding has among its main consequences the exceeding of the levels of
care that can be guaranteed by the hospital. Studies have shown that in some large EDs,
at least 40% of the health care staff spend their time on patients who have already gone
through a medical consultation but are unable to leave the ED due to the above-mentioned
phenomena, rather than taking care of patients in the wards [10].

3.1.4. The Impact of SARS-CoV-2 on ED Overcrowding

Over the past two years, hospitals have faced difficulties brought by the SARS-CoV-2
pandemic, and the effects of the latter on the availability of emergency services and ED
overcrowding are still poorly evaluated [24].
The pandemic has been a challenge for the ED [1,25] in several aspects, and this has
brought changes in the management of staff, patients, and wards. Indeed, potentially
infected patients must be separated from others; staff must wear protective clothing that
limits productivity, and vital parameters must be monitored more frequently. There is a
high risk that this increased workload could result in crowding of the ED [26,27].
It can be observed that the waiting time for hospitalization has lengthened, partly
because of the need to screen all patients before assigning them to a “clean” ward or a
COVID unit, in order to ensure that positive patients, even if asymptomatic, were not
admitted to clean wards contributing to the spread of the virus [10].
The increasing crowding during the pandemic is believed to be due mainly to three
factors: the mismatch between the need for intensive care unit beds and the number of
available beds, the large number of frail patients requiring stabilization before admission
Healthcare 2022, 10, 1625 6 of 13

to hospital wards, and the change in management of all patients [24]. Therefore, ED
overcrowding has been a direct consequence of hospital overcrowding in general [10].
As a result of these two years, it has been noticed that measures are therefore needed
to alleviate crowding and reduce exit block, so that hospitals are prepared to respond
adequately to any future pandemics [24].

3.2. Effects and Consequences of Overcrowding in EDs

The most evident effect of overcrowding in the performance of an ED is an increase in
patient waiting time; this increase causes an increment in the number of patients leaving the
ED before being visited by a physician, which is defined as left without being seen (LWBS);
however, it has been observed that this group of patients complains of a progressive wors-
ening of health conditions and returns shortly afterwards to be hospitalized (return visit).
Several studies have found that the quality of treatment in overcrowded situations worsens
significantly; it has been shown that in patients with myocardial infarction, an increase in
door-to-needle time, the time between patient evaluation and drug administration, was
significantly longer in overcrowded situations compared to normal timing [2]. An Aus-
tralian retrospective study showed a clear increase in mortality of patients admitted to the
ED during an overcrowded shift compared with those admitted during a normal shift. The
authors of this study calculated that there are 13 deaths per year in their hospital due to
overcrowding in the ED [28].
Overcrowding reduces ED capacity, affects quality of care, increases the risk of adverse
outcomes for patients, especially cardiac and intubated patients, and increases the risk of
hospital-acquired infections and the likelihood of patient management errors [29,30].
ED staff also suffer the effects of overcrowding; job satisfaction is affected by these
stressful situations, and overcrowding has been identified as a major reason for staff
reduction [2,31].
The potential financial impact of overcrowding is not insignificant; in fact, the resulting
increase in reconsultations and hospitalizations, worse quality of treatment, dissatisfaction
of health care staff, and morbidity lead to higher treatment costs [2,32]. According to a
study, boarding increases the cost by USD 6.8 million over 3 years. Reducing boarding time
by just one hour would increase revenue by USD 13,298 per day or USD 4.9 million per
year [4,33,34].
Return visit (RV) is often used as a quality indicator for ED because it can be caused by
premature discharge, missed diagnosis, or failure of treatment or discharge planning [35].
RVs not only delay adequate treatment of patients, but also increase resource use and
medical costs [35,36]. Other factors, such as disease progression, lack of improvement, or
patient concern and fear about their condition, contribute to this problem. Overcrowding
is a health problem worldwide that leads to an increase in misdiagnoses and medical
errors [35,37]. ED staff must always provide timely care to urgent patients; therefore, when
the ED is overcrowded, physicians accelerate the patient discharge process to prepare an
empty bed for new patients [2].

3.3. Solution to Overcrowding

Regarding the resolution of overcrowding, several actions are needed, not only at the
medical level but also at the bureaucratic level. These can be divided into two levels that act
in synergy: microlevel and macrolevel strategies [4,10] as shown schematically in Table 3.
Healthcare 2022, 10, 1625 7 of 13

Table 3. Microlevel and macrolevel strategies.

Strategies Solutions
Acceleration of diagnostic pathways
Fast track
Microlevel strategies Outpatient services outside the ED
applied at the level of the Emergency Department Setting home care
Observation unit
Team triage
Artificial intelligence (AI) and machine learning
Simplifying the admission process
Reverse triage
Smoothing elective admissions
Macrolevel strategies
Early discharge
applied at the hospital and/or care system level
Weekend discharge
Full capacity protocol or action plan
Legislation and guidelines

3.3.1. Microlevel Strategies

Microlevel strategies are designed to fight the problem of overcrowding and boarding
and include those changes that can be applied at the level of the ED [4].

Acceleration of Diagnostic Pathways

The use of standardized diagnostic pathways can be extremely useful in the standard-
izing care process, diagnosis, and treatment in order to reduce waiting times, the chance of
error and, in some circumstances, hospitalization rates. They are also crucial in enhancing
outcomes by reducing adverse events and mortality [4,10].
One of the possible strategies is to introduce point-of-care procedures (POCTs) in
EDs. Internal POCTs in EDs offer several advantages over the determination of laboratory
parameters that would normally be conducted in a central laboratory. This reduces sam-
ple transport times and the communication of results from the central laboratory to the
receiver [2,5]. There are promising data in this regard; a recent U.S. study demonstrated a
1 h reduction in average treatment time through the use of point-of-care laboratory testing
in triage [38].

Fast Track
To accelerate the treatment of nonurgent patients with less serious symptoms or
illnesses (green and white codes), an alternative pathway, the so-called “fast track,” has
already been introduced in many EDs. The fast track consists of direct transfer from triage
to a specialist physician. Numerous studies have shown that the introduction of this
accelerated pathway has brought several benefits, not only in terms of reducing the waiting
time and treatment of patients but also in reducing the number of patients who left the ED
before being seen (LWBS) by a physician [2,3,39].

Outpatient Services outside the ED

Another microlevel strategy is to redirect patients accessing the ED to alternative
health care resources by making special reference to outpatient services; in fact, on some
occasions, patients primarily access the ED because they are unable to find their way
around the health care system. This phenomenon is more prevalent among certain social
groups, such as low social classes, low literacy levels, and patients who fear the stigma
and shame associated with certain conditions [5,40,41]. Imaging techniques for noncritical
patients could be taken over by other adequate facilities in order to give priority and ensure
access to emergency diagnostic procedures for critical patients.
Healthcare 2022, 10, 1625 8 of 13

Setting Home Care

Another way that can be taken to reduce overcrowding in EDs is home care. After
appropriate initial diagnosis and stabilization of the patient, for those who do not require
hospitalization, home care can play a key role in the continuation of care.
So, home care brings benefits not only in terms of reducing overcrowding but also in
terms of quality of care and patient satisfaction to different categories of patients. These
benefits have been highlighted especially in the elderly, who find that being able to continue
treatment in a familiar and comfortable environment benefits their health [4,10].

Team Triage
Team triage refers to the triage of patients performed by nurses in conjunction with
physicians. However, some studies have shown conflicting data to date [2]; some of these
found a mortality benefit, but no effect on waiting or treatment time [2]. In contrast, other
studies showed significantly lower treatment time [42].
Another intervention on triage that has been promising is to give nurses more authority,
for example, by giving them the ability to request diagnostic tests, such as X-rays, even
before the physician has examined the patient [5,39,43]. However, it is highly recommended
that nurses acquire adequate training before assuming this additional role [26].
Furthermore, in a study by Debono et al. [44], it was demonstrated that medical or
nursing staff trained to conduct a telephone triage system could decrease the number of
accesses in a pediatric ED, and this possible solution could be extended to other age groups
as well.

Artificial Intelligence (AI) and Machine Learning

AI and machine learning represent a new approach to implement the most effective
strategies to combat the problem of overcrowding. Cabezuelo studied the best set of vari-
ables that explain the phenomenon of the return of patients to the emergency department
of a hospital in less than 72 h. He found that the best machine learning algorithm is a neural
network [45]. Arnaud et al. studied the early prediction of patient hospitalization at the
triage stage applying data analytics [46].

3.3.2. Macrolevel Strategies

Macrolevel strategies can be put into practice to fight the problem of overcrowding
similarly to microlevel strategies, but, unlike the latter, they are applied at the hospital
and/or care system level [4,10].

Simplifying the Admission Process

Simplifying the admission processes could provide better control of patient flows by
reducing waiting times and ensuring better management of overcrowding in EDs [10,47].
Verbal handover between two attending physicians is still the most effective method
to ensure safe and smooth transitions; however, in periods of rapid patient influx or in
academic institutions where students serve as the primary workforce, this can be difficult.
The goal would be to have a standardized admission process used by all inpatient services
in order to reduce delays and potentially maximize hospital service performance.
In hospitals with the capability, a standardized electronic signature process could
enable more efficient and asynchronous admission [4,48].

Reverse Triage
Reverse triage is a process to identify hospitalized patients who are stable and do not
require further treatment and can therefore be discharged without any risk [10,49].
Early discharge from the hospital is also facilitated and supported by cooperation with
external facilities, such as hospices, nursing homes, rehabilitation centers, and the patients’
own homes, of course with a proper support program if necessary [10,49]. The addition of
a 24–48 h postdischarge telemedicine follow-up period, together with reverse triage and
Healthcare 2022, 10, 1625 9 of 13

early discharge processes, can potentially facilitate both caregivers and patients by thereby
promoting the availability of hospital beds for new admissions [4,50].

Smoothing Elective Admissions

Although variability in the number of hospitalizations in emergency medicine cannot
be controlled, studies over time have demonstrated that it is highly predictable based on
weather, season, and epidemiology [51,52]. The remaining hospital admissions are elective
scheduled admissions, which typically are scheduled at the beginning of each week and
have been shown to have a deeply negative impact on overall flow and boarding.
The problematic aspect is related to the fact that elective hospitalizations often compete
with urgent hospitalizations related to ED admissions.
Much work has been done on elective scheduling of surgical hospitalizations, and
this has led to a substantial decrease in boarding and improved bed availability in the
inpatient and intensive care units. Because of the peaks in elective hospitalizations at the
beginning of the week, spreading them evenly over the week would improve the hospital’s
bed capacity [51,53,54].

Early Discharge
Without the early discharge of hospitalized patients, new patients admitted to the ED
are at risk of experiencing boarding. According to a study by Powell et al., to contrast this
issue, early discharge before noon has been shown to improve ED flow, reducing boarding
by 96% [51,55]. It was also found that at New York University, increasing the number of
patients discharged before noon led to an overall reduction in length of stay. Their efforts
were guided by the finding that hospitalized patients arriving at the inpatient unit before
noon had an average length of stay of 0.6 days less than those arriving after noon [17].

Weekend Discharge
On weekends, the number of discharges is usually nearly 50% lower than the number
of discharges on weekdays [51]. The increase in weekend discharges can substantially
increase bed availability earlier in the week and reduce the hospital’s overall LOS. Although
this may require resources that are often unavailable on weekends, such as echographies,
MRIs, and stress tests, increased weekend services result in less demand for them during
the week. For this reason, it is not necessary to increase staffing, but it is sufficient to
redistribute some of it on weekends [17,56].

Full Capacity Protocol or Action Plan

Financial demands require hospitals to operate at nearly full capacity, but when
the capacity is exhausted, hospitals should use a program to manage excess hospitalized
patients and reduce boarding in the ED, such as the full capacity protocol (FCP) that consists
of transferring patients from the hallways of the ED to the hallways of inpatient wards.
The establishment of an FCP has been studied extensively in different settings and has
been shown to reduce waiting time and boarding, improve productivity, reduce overall
length of stay, and improve patient satisfaction [17,51,57].

Legislation and Guidelines

The awareness of the overcrowding problem by members of hospital management is a
key aspect that must be approached to solve the problem [10,49].
In case there is no improvement, despite the possibility of making structural and
organizational changes that could reduce the problem, it is necessary to enhance regulations
and draft stronger legislation to regulate overcrowding, through effective and precise
guidelines, in order to solve the issue at a higher level [7,10].
Healthcare 2022, 10, 1625 10 of 13

3.3.3. Observation Unit

Other strategies that could have a positive impact on hospital admissions are obser-
vation units (OBIs—units of short and intensive observation), which are a link between
microlevel and macrolevel factors, as they are located at the intersection of ED and hospital
care [4,10,58,59].
Patients who may benefit from the presence of an observation unit are those who, after
receiving a diagnosis or starting a treatment, do not require prolonged hospitalization but
need to be kept under observation for a short period of time. Thus, the institution of OBIs
could reduce overcrowding in EDs, while allowing continuous monitoring and treatment
of patients.
An Italian research group showed that over the years of operation of an OBI team, a
stabilization of the phenomena of “boarding” and “exit block” was observed, despite an
increase in the number of ED admissions and the need for hospitalization of the patients
themselves. A containment of the length of stay and improvement in the outcomes of some
categories of patients was also observed [10]; these results are in line with data from other
European and American research groups [10,60,61].

4. Discussion
Considering the growing importance of overcrowding in EDs and its potential effects
on the wellness of patients and employees, the need to develop strategies to deal with or
mitigate the problem has become evident [2]. As has been described, the causes leading
to overcrowding in EDs are multiple, starting with input causes and ending with output
causes. Only knowledge and awareness of the issue can lead us to put in place the most
appropriate strategies to be able to counteract the problem and bring it under control.
In this regard, this review was conducted, starting with an analysis of the causes and
consequences, and then focusing mainly on the strategies that can be used to counteract
this phenomenon.
This review to our knowledge presents a detailed analysis of possible solutions to
overcrowding not reported in other reviews. It also presents a summary of the main
indicators of overcrowding although there is currently no gold standard.
There are several limitations in this narrative review. First, only articles in English
were included, and therefore important information published in other languages may
be missing, as this is a worldwide issue. The studies considered included pediatric EDs
in some cases, with their specific issues, in other Emergency Departments aimed at the
general population.

5. Conclusions
In this regard, numerous strategies have been collected and proposed in order to
be implemented both at the ED level (microlevel strategies) and at the hospital level
(macrolevel strategies). The goal should be to carry out an approach that takes into
consideration not just the ED but also the hospital, the health care system in general, and
the community.

Author Contributions: Conceptualization, M.S., P.C. and M.L.C.; Literature research, A.C. and
M.O.; Writing—original draft preparation, A.C., A.D., L.G. and M.O.; Writing—review and editing,
M.S., A.M.S., P.C., F.C. and M.L.C. All authors have read and agreed to the published version of
the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.
Healthcare 2022, 10, 1625 11 of 13

References
1. Babatabar-Darzi, H.; Jafari-Iraqi, I.; Mahmoudi, H.; Ebadi, A. Overcrowding Management and Patient Safety: An Application of
the Stabilization Model. Iran. J. Nurs. Midwifery Res. 2020, 25, 382. [CrossRef] [PubMed]
2. Lindner, G.; Woitok, B.K. Emergency Department Overcrowding: Analysis and Strategies to Manage an International Phe-
nomenon. Wien. Klin. Wochenschr. 2021, 133, 229–233. [CrossRef] [PubMed]
3. Adriani, L.; Dall’Oglio, I.; Brusco, C.; Gawronski, O.; Piga, S.; Reale, A.; Buonomo, E.; Cerone, G.; Palombi, L.; Raponi, M.
Reduction of Waiting Times and Patients Leaving Without Being Seen in the Tertiary Pediatric Emergency Department: A
Comparative Observational Study. Pediatr. Emerg. Care 2022, 38, 219–223. [CrossRef] [PubMed]
4. Kenny, J.F.; Chang, B.C.; Hemmert, K.C. Factors Affecting Emergency Department Crowding. Emerg. Med. Clin. N. Am. 2020, 38,
573–587. [CrossRef] [PubMed]
5. Yarmohammadian, M.; Rezaei, F.; Haghshenas, A.; Tavakoli, N. Overcrowding in Emergency Departments: A Review of Strategies
to Decrease Future Challenges. J. Res. Med. Sci. 2017, 22, 23. [CrossRef]
6. Badr, S.; Nyce, A.; Awan, T.; Cortes, D.; Mowdawalla, C.; Rachoin, J.-S. Measures of Emergency Department Crowding, a
Systematic Review. How to Make Sense of a Long List. Open Access Emerg. Med. 2022, 14, 5–14. [CrossRef] [PubMed]
7. Rabin, E.; Kocher, K.; McClelland, M.; Pines, J.; Hwang, U.; Rathlev, N.; Asplin, B.; Trueger, N.S.; Weber, E. Solutions To
Emergency Department ‘Boarding’ And Crowding Are Underused And May Need To Be Legislated. Health Aff. 2012, 31,
1757–1766. [CrossRef]
8. American College of Emergency Physicians. Practice Guideline. Definition of Boarded Patient. Ann. Emerg. Med. 2011, 57, 548.
[CrossRef]
9. Emergency Medicine Practice Committee. Emergency Department Crowding: High Impact Solutions. 2016. Available online:
https://www.acep.org/globalassets/sites/acep/media/crowding/empc_crowding-ip_092016.pdf (accessed on 31 May 2022).
10. Savioli, G.; Ceresa, I.F.; Gri, N.; Bavestrello Piccini, G.; Longhitano, Y.; Zanza, C.; Piccioni, A.; Esposito, C.; Ricevuti, G.;
Bressan, M.A. Emergency Department Overcrowding: Understanding the Factors to Find Corresponding Solutions. J. Pers. Med.
2022, 12, 279. [CrossRef]
11. Phillips, J.L.; Jackson, B.E.; Fagan, E.L.; Arze, S.E.; Major, B.; Zenarosa, N.R.; Wang, H. Overcrowding and Its Association With
Patient Outcomes in a Median-Low Volume Emergency Department. J. Clin. Med. Res. 2017, 9, 911–916. [CrossRef]
12. Epstein, S.K.; Huckins, D.S.; Liu, S.W.; Pallin, D.J.; Sullivan, A.F.; Lipton, R.I.; Camargo, C.A. Emergency Department Crowding
and Risk of Preventable Medical Errors. Intern. Emerg. Med. 2012, 7, 173–180. [CrossRef]
13. Carter, E.J.; Pouch, S.M.; Larson, E.L. The Relationship Between Emergency Department Crowding and Patient Outcomes: A
Systematic Review: Emergency Department Crowding and Patient Outcomes. J. Nurs. Scholarsh. 2014, 46, 106–115. [CrossRef]
14. Welch, S.J.; Augustine, J.J.; Dong, L.; Savitz, L.A.; Snow, G.; James, B.C. Volume-Related Differences in Emergency Department
Performance. Jt. Comm. J. Qual. Patient Saf. 2012, 38, 395-AP1. [CrossRef]
15. Asaro, P.V.; Lewis, L.M.; Boxerman, S.B. Emergency Department Overcrowding: Analysis of the Factors of Renege Rate. Acad.
Emerg. Med. 2007, 14, 157–162. [CrossRef] [PubMed]
16. Boldori, H.M.; Ciconet, R.M.; Viegas, K.; Schaefer, R.; dos Santos, M.N. Cross-Cultural Adaptation of the Scale National Emergency
Department Overcrowding Score (NEDOCS) for Use in Brazil. Rev. Gaúcha De Enferm. 2021, 42, e20200185. [CrossRef] [PubMed]
17. Salway, R.; Valenzuela, R.; Shoenberger, J.; Mallon, W.; Viccellio, A. Emergency department (ed) overcrowding: Evidence-based
answers to frequently asked questions. Rev. Médica Clínica Las Condes 2017, 28, 213–219. [CrossRef]
18. Wachtel, G.; Elalouf, A. Addressing Overcrowding in an Emergency Department: An Approach for Identifying and Treating
Influential Factors and a Real-Life Application. Isr. J. Health Policy Res. 2020, 9, 37. [CrossRef]
19. Affleck, A.; Parks, P.; Drummond, A.; Rowe, B.H.; Ovens, H.J. Emergency Department Overcrowding and Access Block. CJEM
2013, 15, 359–370. [CrossRef]
20. Ministero Della Salute. Linee di Indirizzo Nazionali per lo Sviluppo del Piano di Gestione del Sovraffollamento in Pronto soccorso.
Available online: https://www.salute.gov.it/imgs/C_17_pubblicazioni_3143_allegato.pdf (accessed on 31 May 2022).
21. Erenler, A.K.; Akbulut, S.; Guzel, M.; Cetinkaya, H.; Karaca, A.; Turkoz, B.; Baydin, A. Reasons for Overcrowding in the
Emergency Department: Experiences and Suggestions of an Education and Research Hospital. Turk. J. Emerg. Med. 2014, 14,
59–63. [CrossRef] [PubMed]
22. Jung, H.M.; Kim, M.J.; Kim, J.H.; Park, Y.S.; Chung, H.S.; Chung, S.P.; Lee, J.H. The Effect of Overcrowding in Emergency
Departments on the Admission Rate According to the Emergency Triage Level. PLoS ONE 2021, 16, e0247042. [CrossRef]
23. Chen, W.; Linthicum, B.; Argon, N.T.; Bohrmann, T.; Lopiano, K.; Mehrotra, A.; Travers, D.; Ziya, S. The Effects of Emergency
Department Crowding on Triage and Hospital Admission Decisions. Am. J. Emerg. Med. 2020, 38, 774–779. [CrossRef] [PubMed]
24. Savioli, G.; Ceresa, I.F.; Novelli, V.; Ricevuti, G.; Bressan, M.A.; Oddone, E. How the Coronavirus Disease 2019 Pandemic Changed
the Patterns of Healthcare Utilization by Geriatric Patients and the Crowding: A Call to Action for Effective Solutions to the
Access Block. Intern. Emerg. Med. 2022, 17, 503–514. [CrossRef] [PubMed]
25. Al-Surimi, K.; Yenugadhati, N.; Shaheen, N.; Althagafi, M.; Alsalamah, M. Epidemiology of Frequent Visits to the Emergency
Department at a Tertiary Care Hospital in Saudi Arabia: Rate, Visitors’ Characteristics, and Associated Factors. Int. J. Gen. Med.
2021, 14, 909–921. [CrossRef] [PubMed]
26. Bittencourt, R.J.; Stevanato, A.D.M.; Bragança, C.T.N.M.; Gottems, L.B.D.; O’Dwyer, G. Interventions in Overcrowding of
Emergency Departments: An Overview of Systematic Reviews. Rev. De Saúde Pública 2020, 54, 66. [CrossRef]
Healthcare 2022, 10, 1625 12 of 13

27. af Ugglas, B.; Skyttberg, N.; Wladis, A.; Djärv, T.; Holzmann, M.J. Emergency Department Crowding and Hospital Transformation
during COVID-19, a Retrospective, Descriptive Study of a University Hospital in Stockholm, Sweden. Scand. J. Trauma Resusc.
Emerg. Med. 2020, 28, 107. [CrossRef]
28. Richardson, D.B. Increase in Patient Mortality at 10 Days Associated with Emergency Department Overcrowding. Med. J. Aust.
2006, 184, 213–216. [CrossRef]
29. Menon, N.V.B.; Jayashree, M.; Nallasamy, K.; Angurana, S.K.; Bansal, A. Bed Utilization and Overcrowding in a High-Volume
Tertiary Level Pediatric Emergency Department. Indian Pediatr. 2021, 58, 723–725. [CrossRef]
30. Jo, S.; Jeong, T.; Jin, Y.H.; Lee, J.B.; Yoon, J.; Park, B. ED Crowding Is Associated with Inpatient Mortality among Critically Ill
Patients Admitted via the ED: Post Hoc Analysis from a Retrospective Study. Am. J. Emerg. Med. 2015, 33, 1725–1731. [CrossRef]
31. Crook, H.D.; Taylor, D.M.; Pallant, J.F.; Cameron, P.A. Workplace Factors Leading to Planned Reduction of Clinical Work among
Emergency Physicians. Emerg. Med. 2004, 16, 28–34. [CrossRef]
32. Green, D.; Ruel, J. Impact of Advanced Practice Prehospital Programs on Health Care Costs and ED Overcrowding: A Literature
Review. Adv. Emerg. Nurs. J. 2020, 42, 128–136. [CrossRef]
33. Krochmal, P.; Riley, T.A. Increased Health Care Costs Associated with ED Overcrowding. Am. J. Emerg. Med. 1994, 12, 265–266.
[CrossRef]
34. Pines, J.M.; Batt, R.J.; Hilton, J.A.; Terwiesch, C. The Financial Consequences of Lost Demand and Reducing Boarding in Hospital
Emergency Departments. Ann. Emerg. Med. 2011, 58, 331–340. [CrossRef] [PubMed]
35. Kim, D.; Park, Y.S.; Park, J.M.; Brown, N.J.; Chu, K.; Lee, J.H.; Kim, J.H.; Kim, M.J. Influence of Overcrowding in the Emergency
Department on Return Visit within 72 H. J. Clin. Med. 2020, 9, 1406. [CrossRef] [PubMed]
36. Duseja, R.; Bardach, N.S.; Lin, G.A.; Yazdany, J.; Dean, M.L.; Clay, T.H.; Boscardin, W.J.; Dudley, R.A. Revisit Rates and Associated
Costs After an Emergency Department Encounter: A Multistate Analysis. Ann. Intern. Med. 2015, 162, 750–756. [CrossRef]
37. Di Somma, S.; Paladino, L.; Vaughan, L.; Lalle, I.; Magrini, L.; Magnanti, M. Overcrowding in Emergency Department: An
International Issue. Intern. Emerg. Med. 2015, 10, 171–175. [CrossRef]
38. Singer, A.J.; Taylor, M.; LeBlanc, D.; Meyers, K.; Perez, K.; Thode, H.C.; Pines, J.M. Early Point-of-Care Testing at Triage Reduces
Care Time in Stable Adult Emergency Department Patients. J. Emerg. Med. 2018, 55, 172–178. [CrossRef]
39. Oredsson, S.; Jonsson, H.; Rognes, J.; Lind, L.; Göransson, K.E.; Ehrenberg, A.; Asplund, K.; Castrén, M.; Farrohknia, N. A
Systematic Review of Triage-Related Interventions to Improve Patient Flow in Emergency Departments. Scand. J. Trauma Resusc.
Emerg. Med. 2011, 19, 43. [CrossRef]
40. Savioli, G.; Ceresa, I.F.; Maggioni, P.; Lava, M.; Ricevuti, G.; Manzoni, F.; Oddone, E.; Bressan, M.A. Impact of ED Organization
with a Holding Area and a Dedicated Team on the Adherence to International Guidelines for Patients with Acute Pulmonary
Embolism: Experience of an Emergency Department Organized in Areas of Intensity of Care. Medicines 2020, 7, 60. [CrossRef]
41. Lee, I.-H.; Chen, C.-T.; Lee, Y.-T.; Hsu, Y.-S.; Lu, C.-L.; Huang, H.-H.; Hsu, T.-F.; How, C.-K.; Yen, D.H.-T.; Yang, U.-C. A New
Strategy for Emergency Department Crowding: High-Turnover Utility Bed Intervention. J. Chin. Med. Assoc. 2017, 80, 297–302.
[CrossRef]
42. Burström, L.; Nordberg, M.; Örnung, G.; Castrén, M.; Wiklund, T.; Engström, M.-L.; Enlund, M. Physician-Led Team Triage Based
on Lean Principles May Be Superior for Efficiency and Quality? A Comparison of Three Emergency Departments with Different
Triage Models. Scand. J. Trauma Resusc. Emerg. Med. 2012, 20, 57. [CrossRef]
43. Jeyaraman, M.M.; Copstein, L.; Al-Yousif, N.; Alder, R.N.; Kirkland, S.W.; Al-Yousif, Y.; Suss, R.; Zarychanski, R.; Doupe, M.B.;
Berthelot, S.; et al. Interventions and Strategies Involving Primary Healthcare Professionals to Manage Emergency Department
Overcrowding: A Scoping Review. BMJ Open 2021, 11, e048613. [CrossRef] [PubMed]
44. Debono, P.; Debattista, J.; Attard-Montalto, S.; Pace, D. Adequacy of Pediatric Triage. Disaster Med. Public Health Prep. 2012, 6,
151–154. [CrossRef] [PubMed]
45. Sarasa Cabezuelo, A. Application of Machine Learning Techniques to Analyze Patient Returns to the Emergency Department.
J. Pers. Med. 2020, 10, 81. [CrossRef]
46. Arnaud, E.; Elbattah, M.; Gignon, M.; Dequen, G. Deep Learning to Predict Hospitalization at Triage: Integration of Structured
Data and Unstructured Text. In Proceedings of the 2020 IEEE International Conference on Big Data (Big Data), Atlanta, GA, USA,
10–13 December 2020; pp. 4836–4841.
47. Lovett, P.B.; Illg, M.L.; Sweeney, B.E. A Successful Model for a Comprehensive Patient Flow Management Center at an Academic
Health System. Am. J. Med. Qual. 2016, 31, 246–255. [CrossRef] [PubMed]
48. Kelen, G.D.; Wolfe, R.; D’Onofrio, G.; Mills, A.M.; Diercks, D.; Stern, S.A.; Wadman, M.C.; Sokolove, P.E. Emergency Department
Crowding: The Canary in the Health Care System. NEJM Catal. Innov. Care Deliv. 2021, 1–26. [CrossRef]
49. Pollaris, G.; Sabbe, M. Reverse Triage: More than Just Another Method. Eur. J. Emerg. Med. 2016, 23, 240–247. [CrossRef]
50. Syed, S.T.; Gerber, B.S.; Sharp, L.K. Traveling Towards Disease: Transportation Barriers to Health Care Access. J. Community
Health 2013, 38, 976–993. [CrossRef]
51. McKenna, P.; Heslin, S.M.; Viccellio, P.; Mallon, W.K.; Hernandez, C.; Morley, E.J. Emergency Department and Hospital Crowding:
Causes, Consequences, and Cures. Clin. Exp. Emerg. Med. 2019, 6, 189–195. [CrossRef]
52. Boyle, J.; Jessup, M.; Crilly, J.; Green, D.; Lind, J.; Wallis, M.; Miller, P.; Fitzgerald, G. Predicting Emergency Department
Admissions. Emerg. Med. J. 2012, 29, 358–365. [CrossRef]
Healthcare 2022, 10, 1625 13 of 13

53. McManus, M.L.; Long, M.C.; Cooper, A.; Mandell, J.; Berwick, D.M.; Pagano, M.; Litvak, E. Variability in Surgical Caseload and
Access to Intensive Care Services. Anesthesiology 2003, 98, 1491–1496. [CrossRef]
54. Litvak, E.; Fineberg, H.V. Smoothing the Way to High Quality, Safety, and Economy. N. Engl. J. Med. 2013, 369, 1581–1583.
[CrossRef] [PubMed]
55. Powell, E.S.; Khare, R.K.; Venkatesh, A.K.; Van Roo, B.D.; Adams, J.G.; Reinhardt, G. The Relationship between Inpatient
Discharge Timing and Emergency Department Boarding. J. Emerg. Med. 2012, 42, 186–196. [CrossRef] [PubMed]
56. Wong, H.J.; Wu, R.C.; Caesar, M.; Abrams, H.; Morra, D. Smoothing Inpatient Discharges Decreases Emergency Department
Congestion: A System Dynamics Simulation Model. Emerg. Med. J. 2010, 27, 593–598. [CrossRef] [PubMed]
57. Garson, C.; Hollander, J.E.; Rhodes, K.V.; Shofer, F.S.; Baxt, W.G.; Pines, J.M. Emergency Department Patient Preferences for
Boarding Locations When Hospitals Are at Full Capacity. Ann. Emerg. Med. 2008, 51, 9–12.e3. [CrossRef]
58. Aaronson, E.L.; Yun, B.J. Emergency Department Shifts and Decision to Admit: Is There a Lever to Pull to Address Crowding?
BMJ Qual. Saf. 2020, 29, 443–445. [CrossRef]
59. Ross, M.A.; Hockenberry, J.M.; Mutter, R.; Barrett, M.; Wheatley, M.; Pitts, S.R. Protocol-Driven Emergency Department
Observation Units Offer Savings, Shorter Stays, And Reduced Admissions. Health Aff. 2013, 32, 2149–2156. [CrossRef]
60. Al-Kuwaiti, A.; Hefny, A.F.; Bellou, A.; Eid, H.O.; Abu-Zidan, F.M. Epidemiology of Head Injury in the United Arab Emirates.
Turk. J. Trauma Emerg. Surg. 2012, 18, 213–218. [CrossRef]
61. Lim, A.G.; Kivlehan, S.; Losonczy, L.I.; Murthy, S.; Dippenaar, E.; Lowsby, R.; Yang, M.L.C.L.C.; Jaung, M.S.; Stephens, P.A.;
Benzoni, N.; et al. Critical Care Service Delivery across Healthcare Systems in Low-Income and Low-Middle-Income Countries:
Protocol for a Systematic Review. BMJ Open 2021, 11, e048423. [CrossRef] [PubMed]