International Journal of Advanced Health Science and Technology

Multidisciplinary : Rapid Review : Open Access Journal e-ISSN:2808-6422; p-ISSN:2829-3037

RESEARCH ARTICLE OPEN ACCESS

Manuscript received February 5, 2023; revised March 20, 2023; accepted April 20, 2023; date of publication April 30, 2023
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How to cite: Yusron Amin and Haswita, “Emergency Department Overcrowding and Its Potential Impact on Care Processes: A Literature
Review”, International Journal of Advanced Health Science and Technology, vol. 3, no. 2, pp. 92–98, April. 2023.

Emergency Department Overcrowding and Its

Potential Impact on Care Processes: A
Literature Review
Yusron Amin and Haswita
Diploma of Nursing, School of Nursing Science (STIKES) Rustida, Indonesia
Corresponding author: Yusron Amin (e-mail: [email protected]).
This study was supported by STIKES Rustida

ABSTRACT Emergency department overcrowding was a obstacle of providing timely and effective care in emergency
department. This condition had negatively impact on many aspect of care proccess. There were different finding related to
impact of emergency department overcrowding in care process. The aim of the study was to analyze research articles that
discusses emergency department overcrowding and its potential impact on care proccess. The study was literature review using
database journal resources from PubMed, Proquest, and ScienceDirect. Emergency department (ED), Overcrowding, and
impact we used as keyword. Inclusion criteria of the study were original article, Published at 10 years later (2012-2022), written
in english language, focus on patient, staff, or health care system level. Whereas, the exclusion criteria were overcrowding
because of other condition (endemic or infection disease), and not focus on patient, staff, or health care system. 9 selected
articles that met inclusion criteria were analysed based on author, years, title, and main idea of the study. The finding of the
study were emergency department overcrowding had negatively impact on care process including patients, staff, and healthcare
system. Impact on patients including increasing mortality and admission rate, impact on staff including increasing workload
and non-adherence for practicing best guidelines, meanwhile impact on healthcare system including innapropriate triage
proccess and increasing Length of Stay (LOS). Need an effort to decrease impact of ED overcrowding especially on patient,
staff, and healthcare system. The result of the study could be used as considering to formulate an effort to reduce impact of ED
overcrowding by controlling patient, staff, and healthcare system factors

INDEX TERMS overcrowding, emergency department (ED), literature review

I. INTRODUCTION of deteriorate condition. In South Korea, there were increasing

Emergency department was a front of hospital healthcare that emergency department visiting patients up to 4,9 million
expected to provide timely and effective care [1]. However, patients in 2012, from which 995.326 patients (20%) in
implementation of effective care in emergency department hospital admission because of deteriorate condition [6].
was very complex and difficult, it depended on many factors Emergency department overcrowding had effect on
as causes. The one is overcrowding [2]. Emergency decreasing quality of healthcare services, such as delaying
department overcrowding was defined as condition when medication time [7], increasing mortality rate of admitted
increasing need for emergency services exceeds available patients [8,9]. Other effects were prolonged waiting times for
resources in emergency department or hospital [3,4]. triage and treatment [10], decreasing patient satisfaction[11],
Emergency department overcrowding was one obstacle and hospital profit loss [12].
factors in caring processes of patients [4]. Ireland, Canada, and There were some different finding related to impact of
Australia had been experiencing significant and sustainable emergency department overcrowding in care process [13].
increases in emergency department performance and Previous studies proved that emergency department
enhancing number of visiting patients as manifestation of overcrowding effect on three aspects including patient, staff,
emergency department overcrowding [5]. In United States, and healthcare system level [14]. Some studies proved that
there were increasing of visiting patients in emergency impact on patient including delaying getting health care and
department was about 131 million in 2012, from which 14,5 increasing inpatient mortality [15], other studies focused on
million (11%) had in hospital admission, meanwhile 13% of
patients number were carry out into intensive care unit because
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healthcare system impact including ineffective triage process study were original article, articles in english language,
and increasing Length of Stay (LOS) [16,17]. Publish at 10 years later (2012-2022), discuss specific impact
Based on patient effect, there were contradicted finding of ED overcrowding on patient, staff, or health care system
related to impact of ED overcrowding on patient [18]. Some level. Whereas, exclusion criteria were not original article,
studies reported that increasing inpatient mortality was not overcrowding because of other contributed factors (endemic
correlation with emergency department overcrowding [19,20]. or infection disease), not focus effect on patient, staff, or health
Increasing inpatient mortality was happened because of their care. The last step was article included. There were 9 articles
disease severity (majority on patient with Acute Coronary were selected because met inclusion criteria and eligible to
Syndrome (ACS) [21]. But other study reported that analyse. The process of searching articles be presented in
emergency department overcrowding had impact on FIGURE 1.
increasing rate events of cardiovascular patients with both
acute coronary syndrome (ACS) and non-ACS related to chest
Articles identified based on
pain admitted to emergency department [22]. title/abstract (n=122)
Based on health care system, there were also contradicted Pubmed =12
findings related to impact of ED overcrowding to health care ScienceDirect=90
system. Some study proved that ED overcrowding impact to Proquest = 20
timing and modality of triage process, there was increasing
waiting time for first triage process conducted, so it impact on Duplicate (n=14)
delaying diagnosis and initiation of treatment [23]. But other
study proved that triage processes including timing and triage
decision were not depended on condition of ED Articles screened
(overcrowding), but depended on ED resources and patient (n=108)
severity condition [24].
The findings of the study was emergency department Initial screening
overcrowding negatively had impact on patient, staff, and (n=48)
healthcare system level. Impact on patient including Articles reviewed
increasing mortality and admission rate. Impact on staff were (n=60)
increasing workload and non-adherence for practicing best
guidelines. and impact on healthcare system including triage Review
process and Length of Stay (LOS). Based on this (n=24)
phenomenon, the researcher intent to identify several recent
Articles selected based on
articles related to impact of ED overcrowding on care proccess
inclusion criteria (n=12)
using articles that publish at least 10 years recent (2012-2022).
The study goal was to examine integrative studies related to Inclusion criteria
impact of ED overcrowding on patient, staff, and health care
system. Articles included
(n=9)
II. MATERIAL AND METHODS
Study design was literature review using PRISMA approach FIGURE 1. Data Selection Proccess From Journal Database
that consisted of four steps including identification, screening,
eligibility, and included. Identification was searching articles III. RESULTS
from journal databases sources. This study using PubMed Based on result of the articles that had been analysed, we
(MEDLINE), Proquest, and ScienceDirect to identify articles
classified or categories articles into year of publish, place of
based on title/ abstrack that same with the purpose of the study.
aticles publish, and main idea of articles. Based on year of
In this section, we found 122 articles from pubmed (n=12
publish, majority articles (7 articles) were publish at 5 years
articles), ScienceDirect (n=90), and Proquest (n=20). After the
title/ abstract identified , the articles that duplicated were later (2018-2022), and 2 articles was published between 2012
excluded (n=14). to 2017. Based on place of published, majority articles were
The second steps was screening. In this study, there were published in USA (3 articles), followed by Canada (2 articles),
108 articles available based on quality of article components Sweden (1 article), Netherland (1 article), South Korea (1
including title, abstract, introduction, methods, result, article), and Saudi Arabia (1 article). Based on main idea of
discussion, and other information. Using manual screening, the study, majority studies discusses about impact of ED
there were 48 articles exluded related to low level of study. 60 overcrowding on patients (4 articles), healthcare system (3
articles reviewed because of met standart as PRISMA articles), and staff (2 articles). The summaries of articles had
considered. The third step was eligibility. In this section, there been analysed and presented in TABLE 1.
were 24 articles reviewed were excluded because of non
specific discuss about ED overcrowding, whereas 12 articles
accessed based on inclusion criteria. Inclusion criteria of the

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TABLE 1
Summaries of Article about Emergency Department and Its Impact on Care Process
Author Title of article Country Main idea of the study (Result)
Castner & Emergency Department New York 1) Emergency department overcrowding impact on increasing
Suffoletto (2018) Crowding and Time at the (USA) physician- patient contacting time
[25] Bedside: A Wearable 2) There were no correlation for (patient gender, triage acuity
Technology Feasibility level, shift at arrival, disposition to home, or discharge
Study diagnosis category) with increasing physician- patient
contacting time
Chen at al. (2020) The effects of emergency USA 1) There were significant correlation between ED overcrowding
[26] department crowding on with triage or disposition decision
triage and hospital 2) Increasing ED occupancy was found on patient with higher
admission decisions level of triage acuity and hospital admission
Connor et al. Evaluating the effect of Canada ED overcrowding impacted on changing triage destination (need
(2014) emergency department more long time for triage, many patient not to be triaged), more
[27] crowding on triage longer for investigation, and increasing number of unscheduled
destination patient return to ED
Khutbani et al. Association between Saudi Arabia 1) There were correlation between ED overcrowding with
(2020) Emergency Department mortality rate of ED patients
[28] Overcrowding and 2) There were increasing number of mortality patient in ED
Mortality at a Teaching during overcrowding (38%) that dominated patient age (30-
Hospital in Saudi Arabia 44 years), 60 and 74 years old
3) Highest number of patients was dominated by patient triage
at level four (62,7%), and level five (33,1%)
4) There were increasing admission rate during ED
overcrowding
Jung et al. (2021) The effect of South Korea 1) Level of ED overcrowding was dominated by high level
[29] overcrowding in (34%), low level (33,9%), and normal level (32,1%)
emergency departments 2) There was correlation between ED overcrowding with
on the admission rate patient admission rate
according to the 3) Increasing admission rate was experienced by patient triage
emergency triage level with high level (4,5)
Linden et al. Emergency department Netherlands 1) ED overcrowding impacted on triage process (more
(2016) crowding affects triage prolonged time for triage) and increasing od ED Leng of Stay
[30] processes (LOS)
2) ED overcrowding did not effected to triage destination
3) Triage process was not effective during overcrowding (time
for triage more often elapsed, and more patients were not
triaged)
Ouyang et al. The impact of emergency Canada 1) ED overcrowding had positive correlation with patient
(2022) department crowding on admission and physician workload
[31] admission decisions and 2) ED overcrowding had negative correlation with number of
patient outcomes boarding patients
3) There was positive correlation between patient readmission
7 days after hospitalization with number of boarding patients
Berg et al. (2019) Associations Between Sweden 1) There was positive correlation between ED overcrowding
[32] Crowding and Ten-Day with 10 days mortality rate
Mortality Among Patients 2) Higher mortality was found on patient with aged 80 years or
Allocated Lower Triage older (51%) and triage with acuity level 3 (63,3%) dan had
Acuity Levels Without greater comorbidity
Need of Acute Hospital 3) Increasing 10 days mortality was found on patient with ED
Care on Departure From LOS greater than or equal 8 hours
the Emergency 4) Majority ED occupation was found in ratio quartile 2,3, dan
Department 4
Abir et al. (2019) Evaluating the impact of USA 1) ED overcrowding effected to decreasing of patient
[33] emergency department hospitalization, but enhancing patient discharging
crowding on disposition 2) There was increasing number of patient return to ED after 2
patterns and outcomes of weeks with deteriorate condition
discharged patiets

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IV. DISCUSSION treatment and other diagnostic test, so this condition tend to
A. IMPACT OF EMERGENCY DEPARTMENT increasing Length of Stay (LOS) in emergency department
OVERCROWDING ON PATIENT [56]. Increasing LOS both in emergency department and
Based on patient mortality rate, study result showed that hospital ward affected by overcrowding and other factors
there was correlation between emergency department (patient disease complexity and other comorbidity).
overcrowding with mortality rate of ED patients [28,34,35].
There were increasing number of mortality patient in ED C. IMPACT OF EMERGENCY DEPARTMENT
during overcrowding. This result was contradicted with other OVERCROWDING ON STAFF
study that increasing mortality patients do not directly Based on workload, there was correlation between ED
happened because of ED overcrowding, but also effected by overcrowding with ED physician workload [31,57,58].
increasing Length of Stay (LOS), patients age, and level of There were increasing of physician workload while ED
triage aquity [22,36,37]. Increasing 10 days mortality was overcrowding. Increasing physician workload was also
found on patient with ED LOS more than or equal 8 hours, related by increasing of patient admission that dominated by
with age more than 80 years old, and triage with level aquity patients with high level acuity (triage at level 4 and 5)
3 [38]. Increasing mortality patient in emergency department [29,59,60]. The result was similar with other study that ED
was primarily affected by overcrowding and other overcrowding made increasing time of contacting between
contributed factors (patients age and severity condition). patient- physician that effected to workload, but there were
Based on patient admission rate, there was correlation also supported by other contributed factor including patient
between emergency department overcrowding with patient gender, triage acuity level, shift at arrival, disposition to
admission rate [29,39,40,41]. There were increasing patient home, or discharge diagnosis category [25,61,62]. Based on
admission rate during overcrowding that dominated by non-adherence for implementing of best practice guidelines,
patient with triage level acuity 4 and 5. This result was overcrowding in emergency department had negatively
contradicted with other study that emergency department impact on implementation of best practice guidelines by
overcrowding had impact on increasing patient discharging, physician and nurses [63,64,65]. There were increasing
not patient admission [32,42,43]. When overcrowding in ED, incidents of non-adherence for implementing of practice
patient with triage high acuity at level 4 and 5 was discharged guidelines by ED staff (physician and nurses) during ED
without any early treatment in ED, finally the patient would overcrowding. This condition caused by decreasing of focus
return to ED after 2 weeks with deteriorate condition level and exhaustion related to enhancing workload during
[32,44]. Increasing incidents of patients admission in ED overcrowding, especially when facing patients with
emergency department was primarily affected by deteriorate condition (stroke, acute coronary syndrome
overcrowding and other contributed factors (patients triage (ACS) [64,66]. Whereas, other studies reported that events
level acuity and finally decision by physician). of non-adherence for practicing best guidelines by ED staff
B. IMPACT OF EMERGENCY DEPARTMENT not caused by ED overcrowding, but based on supporting of
OVERCROWDING ON HEALTH CARE SYSTEM ED management, facilities, and their self efficacy [62,65,67].
Based on triage process, the study result proved there was increasing incidents of non-adherence for best practicing
significant correlation between ED overcrowding with triage guideliness was affected by ED overcrowding and supported
or disposition decision [26,45,46]. There were increasing by other factors (internal based on self efficacy of staff and
patient with higher level of triage aquity (at level 4,5) during external from hospital management)
ED overcrowding [47]. The result was similar with other
study that ED overcrowding impact on changing triage V. CONCLUSION AND RECOMMENDATION
destination [27]. There were changing of triage process when Emergency department overcrowding negatively impact on
ED overcrowding (need more time to initiate triage, many patient, healthcare system, and staff. Impact on patient
patients not to be triaged). Whereas, other study proved that including increasing mortality rate and patient admission.
ED overcrowding did not effect on triage destination, but Impact on healthcare system including ineffective triage
effect on Length of Stay [30,48,49]. Triage process could not proccess and increasing Length of Stay (LOS) both in ED
conducted optimally during overcrowding, many patient and hospital ward. Meanwhile, impact on staff including
directly to treated or discharging by the physician [50]. So increasing workload and non-adherence for practicing best
implementing of triage proccess when ED overcrowding was guidelines. Need an effort to decrease impact of ED
not effective without any supported by number and quality overcrowding especially on patient, staff, and healthcare
of staff ED (physician and nurses). system. The result of the study could be used as considering
Based on Length of Stay (LOS). The study found that to formulate an effort to reduce impact of ED overcrowding
there was correlation between ED overcrowding with Length by controlling patient, staff, and healthcare system factors.
of Stay (LOS) [30,51,52]. There were increasing LOS both
in emergency department and hospital ward during ACKNOWLEDGEMENT
overcrowding [30,53]. Whereas, other study proved that The researchers appreciated all person who had participated
increasing Leng of Stay (LOS) was happened related to to this study, including Head of STIKES Rustida and the
patient disease complexity and other comorbidity [29,54,55]. entire academic staff who giving support and providing the
Patient with severe condition need more long time for opportunities to conduct the study. We hope that the result of
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