Measures of Emergency Department Crowding, a Systematic Review. How to Make Sense of a Long List

Validation of the Emergency Department Work Index in a Pediatric Freestanding Community Emergency Department

OBJECTIVES

The Emergency Department Work Index (EDWIN) is a validated overcrowding score shown to correlate well with staff assessment of adult emergency department (ED) overcrowding and the potential need for diversion. It derives from the number of staffed ED beds, attending physicians on duty, patients within each triage category, and admitted patients. To date, no study has validated EDWIN in a pediatric community ED setting. We aim to determine if EDWIN correlates with established overcrowding measures and provider perception of overcrowding within a freestanding, community-based pediatric ED.

METHODS

In this prospective observational study at a freestanding, community-based pediatric ED, EDWIN was calculated hourly over 8 weeks throughout the year. EDWIN was compared with other objective and previously established ED metrics of overcrowding, including rates of patients who left without being seen (LWBS), average time from arrival to ED room, average length of stay (LOS), ED occupancy rates, and number of patients in the waiting room. Furthermore, EDWIN was compared with provider perception of overcrowding by surveying providers 6 times a day during the study period using novel, real-time, longitudinal, electronic health record-based survey distribution methodology. Spearman correlation coefficients were calculated to characterize the associations between EDWIN vs provider perception and EDWIN vs ED metrics. ANOVA and Tukey HSD were used to compare means of ED metrics of overcrowding across EDWIN severity categories.

RESULTS

Five hundred eleven provider perception survey responses were collected from July 2022 through January 2023. EDWIN directly correlated with all measures of overcrowding, including provider perception of crowdedness (rho = 0.67), LWBS rates (rho = 0.44), average time from arrival to ED room (rho = 0.74), average LOS (rho = 0.70), ED occupancy rates (rho = 0.68), and number of patients in the waiting room (rho = 0.65). All findings were statistically significant (P < 0.05).

CONCLUSIONS

Our findings suggest that EDWIN is an accurate tool to measure overcrowding in a freestanding, community-based pediatric ED.

Diagnosing patient flow issues in the emergency department: an Australasian hospital case study

PURPOSE

This study investigates how a hospital can increase the flow of patients through its emergency department by using benchmarking and process improvement techniques borrowed from the manufacturing sector.

DESIGN/METHODOLOGY/APPROACH

An in-depth case study of an Australasian public hospital utilises rigorous, multi-method data collection procedures with systems thinking to benchmark an emergency department (ED) value stream and identify the performance inhibitors.

FINDINGS

High levels of value stream uncertainty result from inefficient processes and weak controls. Reduced patient flow arises from senior management's commitment to simplistic government targets, clinical staff that lack basic operations management skills, and fragmented information systems. High junior/senior staff ratios aggravate the lack of inter-functional integration and poor use of time and material resources, increasing the risk of a critical patient incident.

RESEARCH LIMITATIONS/IMPLICATIONS

This research is limited to a single case; hence, further research should assess value stream maturity and associated performance enablers and inhibitors in other emergency departments experiencing patient flow delays.

PRACTICAL IMPLICATIONS

This study illustrates how hospital managers can use systems thinking and a context-free performance benchmarking measure to identify needed interventions and transferable best practices for achieving seamless patient flow.

ORIGINALITY/VALUE

This study is the first to operationalise the theoretical concept of the seamless healthcare system to acute care as defined by Parnaby and Towill (2008). It is also the first to use the uncertainty circle model in an Australasian public healthcare setting to objectively benchmark an emergency department's value stream maturity.

The Effects of Displaying the Time Targets of the Manchester Triage System to Emergency Department Personnel: Prospective Crossover Study

BACKGROUND

The use of triage systems such as the Manchester Triage System (MTS) is a standard procedure to determine the sequence of treatment in emergency departments (EDs). When using the MTS, time targets for treatment are determined. These are commonly displayed in the ED information system (EDIS) to ED staff. Using measurements as targets has been associated with a decline in meeting those targets.

OBJECTIVE

This study investigated the impact of displaying time targets for treatment to physicians on processing times in the ED.

METHODS

We analyzed the effects of displaying time targets to ED staff on waiting times in a prospective crossover study, during the introduction of a new EDIS in a large regional hospital in Germany. The old information system version used a module that showed the time target determined by the MTS, while the new system version used a priority list instead. Evaluation was based on 35,167 routinely collected electronic health records from the preintervention period and 10,655 records from the postintervention period. Electronic health records were extracted from the EDIS, and data were analyzed using descriptive statistics and generalized additive models. We evaluated the effects of the intervention on waiting times and the odds of achieving timely treatment according to the time targets set by the MTS.

RESULTS

The average ED length of stay and waiting times increased when the EDIS that did not display time targets was used (average time from admission to treatment: preintervention phase=median 15, IQR 6-39 min; postintervention phase=median 11, IQR 5-23 min). However, severe cases with high acuity (as indicated by the triage score) benefited from lower waiting times (0.15 times as high as in the preintervention period for MTS1, only 0.49 as high for MTS2). Furthermore, these patients were less likely to receive delayed treatment, and we observed reduced odds of late treatment when crowding occurred.

CONCLUSIONS

Our results suggest that it is beneficial to use a priority list instead of displaying time targets to ED personnel. These time targets may lead to false incentives. Our work highlights that working better is not the same as working faster.

Cost analysis of one-time intravenous antibiotic doses in the emergency department

BACKGROUND

Research shows that one-time doses of intravenous (IV) antibiotics do not improve resolution of infection. However, providers continue to use them-especially in the emergency department (ED). Very few studies have aimed to quantify the cost of this practice.

OBJECTIVES

The primary objective was to evaluate the difference in average total cost of ED stay between patients who received a one-time dose of IV antibiotics in the ED before discharging on oral antibiotics and patients who were just discharged on oral antibiotics. Secondary objectives were to evaluate the differences in durations of stay between the 2 groups, as well as the differences in adverse drug effects and need for health care contact after discharge.

METHODS

Chart review was conducted to identify patients who received and did not receive a one-time dose of IV antibiotics in the ED between April 30, 2020, and April 30, 2022. A microcosting approach was used to determine ED-associated costs per patient. Comparisons in primary and secondary outcomes were performed using statistical inferential tests.

RESULTS

A total of 102 patients were analyzed in each group. Patients who received a one-time dose of IV antibiotics in the ED before being discharged on oral antibiotics had an average length of stay of 4.55 hours, as opposed to patients who did not receive a one-time dose of IV antibiotics before being discharged on oral antibiotics who had an average length of stay of 2.82 hours (absolute difference 1.73 hours, P < 0.001). One-time dosing of IV antibiotics in the ED incurred an additional cost of approximately $556 per patient, totaling to more than $56,000 in our study cohort.

CONCLUSION

The use of one-time IV antibiotics in the ED did not confer any additional benefits to patients. The use of one-time doses resulted in statistically significant reduced throughput in the ED and statistically significant increased health care costs.

Perceived Causes and Effects of Overcrowding Among Nurses in the Emergency Departments of Tertiary Hospitals: A Multicenter Study

Purpose

Emergency department (ED) overcrowding is a significant concern in many hospitals in Saudi Arabia, resulting in long waiting times, delays in treating patients who need urgent care, and, consequently, decreased patient satisfaction. Additionally, ED overcrowding has been linked to increased nurse turnover rates. Therefore, this study aimed to assess nurses' perceived causes and effects of overcrowding in the EDs of five tertiary hospitals in Saudi Arabia.

Methods

This study used a descriptive cross-sectional design. We surveyed 311 nurses working in the EDs of five tertiary hospitals in Saudi Arabia using the convenience sampling technique. The self-administered questionnaires used in the study were developed by the researchers. The study was conducted from October 16 to November 10, 2022. Consensus-Based Checklist for Reporting of Survey Studies was followed.

Results

The results revealed that the primary perceived causes of ED overcrowding in five tertiary hospitals were unnecessary visits due to a lack of standard procedures (mean = 2.70; SD = 0.58) and lack of inpatients beds (mean = 2.69; SD = 0.65). The perceived effect of overcrowding was stress and burnout among nurses (mean = 2.85; SD = 0.47). The perceived causes and effects of overcrowding in the ED were found to be highly significant (p <0.001) based on Pearson correlation and Spearman's rank correlation.

Conclusion

Unnecessary visits due to a lack of standard procedures lead to overcrowding. In addition, a lack of inpatient beds in the ED affects the care provided to patients seeking immediate medical attention. This may prolong patient waiting time, causing their conditions to deteriorate and prolonging hospital stay. Overcrowding leads to increased stress and burnout among nurses. The results of this study can be used to develop a comprehensive action plan to address ED overcrowding and its effects on patients, staff, and ED flow.

An Effective Methodology for Scoring to Assist Emergency Physicians in Identifying Overcrowding in an Academic Emergency Department in Thailand

BACKGROUND

Emergency Department (ED) overcrowding is a global concern, with tools like NEDOCS, READI, and Work Score used as predictors. These tools aid healthcare professionals in identifying overcrowding and preventing negative patient outcomes. However, there's no agreed-upon method to define ED overcrowding. Most studies on this topic are U.S.-based, limiting their applicability in EDs without waiting rooms or ambulance diversion roles. Additionally, the intricate calculations required for these scores, with multiple variables, make them impractical for use in developing nations.

OBJECTIVE

This study sought to examine the relationship between prevalent ED overcrowding scores such as EDWIN, occupancy rate, and Work Score, and a modified version of EDWIN newly introduced by the authors, in comparison to the real-time perspectives of emergency physicians. Additionally, the study explored the links between these overcrowding scores and adverse events related to ED code activations as secondary outcomes.

METHOD

The method described in the provided text is a correlational study. The study aims to examine the relationship between various Emergency Department (ED) overcrowding scores and the real-time perceptions of emergency physicians in every two-hour period. Additionally, it seeks to explore the associations between these scores and adverse events related to ED code activations.

RESULTS

The study analyzed 459 periods, with 5.2% having Likert scores of 5-6. EDOR had the highest correlation coefficient (0.69, p < 0.001) and an AUC of 0.864. Only EDOR significantly correlated with adverse events (p = 0.033).

CONCLUSION

EDOR shows the most robust link with 'emergency physicians' views on overcrowding. Additionally, elevated EDOR scores correlate with a rise in adverse events. Emergency physicians' perceptionof overcrowding could hint at possible adverse events. Notably, all overcrowding scores have high negative predictive values, efficiently negating the likelihood of adverse incidents.

Measuring Emergency Department Workload Perception Using Electronic Medical Record Measures of Patient Volume and Acuity

BACKGROUND

Workload in the emergency department (ED) fluctuates and there is no established model for measurement of clinician-level ED workload.

OBJECTIVE

The aim of this study was to measure perceived ED workload and assess the relationship between perceived workload and objective measures of workload from the electronic medical record (EMR).

METHODS

This study was conducted at a tertiary care, academic ED from July 1, 2020 through April 13, 2021. Attending workload perceptions were collected using a 5-point scale in three care areas with variable acuity. We collected eight EMR measures thought to correlate with perceived workload. EMR values were compared across areas of the department using ANOVA and correlated with attending workload ratings using linear regression.

RESULTS

We collected 315 unique workload ratings, which were normally distributed. For the entire department, there was a weak positive correlation between reported workload perception and mean percentage of inpatient admissions (r = 0.23; p < 0.001), intensive care unit admissions (r = 0.2; p < 0.001), patient arrivals per shift (r = 0.14; p = 0.017), critical care billed visits (r = 0.22; p < 0.001), cardiopulmonary resuscitation code activations (r = 0.2; p < 0.001), and level 5 visits (r = 0.13; p = 0.02). There was weak negative correlation for ED discharges (r = -0.23; p < 0.001). Several correlations were stronger in individual care areas, including percent admissions in the lowest-acuity area (r = 0.43; p = 0.033) and patient arrivals in the highest-acuity area (r = 0.44; p < .01). No significant correlation was found in any area for observation admissions or trauma activations.

CONCLUSIONS

In this study, EMR measures of workload were not closely correlated with ED attending physician workload perception. Future study should examine additional factors contributing to physician workload outside of the EMR.

Developing a set of emergency department performance measures to evaluate delirium care quality for older adults: a modified e-Delphi study

BACKGROUND

Older adults are at high risk of developing delirium in the emergency department (ED); however, it is under-recognized in routine clinical care. Lack of detection and treatment is associated with poor outcomes, such as mortality. Performance measures (PMs) are needed to identify variations in quality care to help guide improvement strategies. The purpose of this study is to gain consensus on a set of quality statements and PMs that can be used to evaluate delirium care quality for older ED patients.

METHODS

A 3-round modified e-Delphi study was conducted with ED clinical experts. In each round, participants rated quality statements according to the concepts of importance and actionability, then their associated PMs according to the concept of necessity (1-9 Likert scales), with the ability to comment on each. Consensus and stability were evaluated using a priori criteria using descriptive statistics. Qualitative data was examined to identify themes within and across quality statements and PMs, which went through a participant validation exercise in the final round.

RESULTS

Twenty-two experts participated, 95.5% were from west or central Canada. From 10 quality statements and 24 PMs, consensus was achieved for six quality statements and 22 PMs. Qualitative data supported justification for including three quality statements and one PM that achieved consensus slightly below a priori criteria. Three overarching themes emerged from the qualitative data related to quality statement actionability. Nine quality statements, nine structure PMs, and 14 process PMs are included in the final set, addressing four areas of delirium care: screening, diagnosis, risk reduction and management.

CONCLUSION

Results provide a set of quality statements and PMs that are important, actionable, and necessary to a diverse group of clinical experts. To our knowledge, this is the first known study to develop a de novo set of guideline-based quality statements and PMs to evaluate the quality of delirium care older adults receive in the ED setting.

Violence against nurses by patients and visitors in the emergency department: An integrative review

AIM

This integrative review explored violence against emergency nurses by patients/visitors, examining its nature, contributing factors and consequences.

DESIGN

Integrative review.

DATA SOURCES

Articles were obtained from PubMed, CINAHL, EMBASE, Web of Science and PsycInfo databases, up until December 2021.

REVIEW METHODS

26 articles were reviewed, evaluating study quality with the Crowe Critical Appraisal Tool and synthesizing conclusions through theme development and coding.

RESULTS

This review delves into the issue of violence perpetrated against emergency nurses by patients and visitors. It elucidates three overarching themes: the nature of violence, the contributing factors and the consequences of such acts.

CONCLUSION

The findings inform healthcare policy for the development of prevention approaches while identifying research gaps and emphasizing the need for alternative study designs and methodologies.

IMPACT

This review has implications for nursing practice, policymaking and research, emphasizing the need for stakeholder engagement and tailored interventions for at-risk emergency nurses.

NO PATIENT OR PUBLIC CONTRIBUTION

This project was an integrative review of the literature therefore no patient or public contribution was necessary.

WHAT ALREADY IS KNOWN

Violence by patients and visitors in healthcare settings, especially in emergency departments, has garnered considerable attention.

WHAT THIS PAPER ADDS

This review specifically examines violence-targeting emergency department nurses from patients and visitors, assessing its characteristics, contributing factors and consequences.

IMPLICATIONS FOR PRACTICE/POLICY

The findings will guide stakeholder engagement in developing interventions to support vulnerable emergency nurses.

Strategies to Measure and Improve Emergency Department Performance: A Review

Emergency Departments (EDs) globally face escalating challenges such as overcrowding, resource limitations, and increased patient demand. This study aims to identify and analyze strategies to enhance the structural performance of EDs, with a focus on reducing overcrowding, optimizing resource allocation, and improving patient outcomes. Through a comprehensive review of the literature and observational studies, the research highlights the effectiveness of various approaches, including triage optimization, dynamic staffing, technological integration, and strategic resource management. Key findings indicate that tailored strategies, such as implementing advanced triage protocols and leveraging telemedicine, can significantly reduce wait times and enhance patient throughput. Furthermore, evidence suggests that dynamic staffing models and the integration of cutting-edge diagnostic tools contribute to operational efficiency and improved quality of care. These strategies, when combined, offer a multifaceted solution to the complex challenges faced by EDs, promising better patient care and satisfaction. The study underscores the need for a comprehensive approach, incorporating both organizational and technological innovations, to address the evolving needs of emergency healthcare.

Emergency Department Volume, Severity, and Crowding Since the Onset of the Coronavirus Disease 2019 Pandemic

STUDY OBJECTIVE

We describe emergency department (ED) visit volume, illness severity, and crowding metrics from the onset of the coronavirus disease 2019 (COVID-19) pandemic through mid-2022.

METHODS

We tabulated monthly data from 14 million ED visits on ED volumes and measures of illness severity and crowding from March 2020 through August 2022 compared with the same months in 2019 in 111 EDs staffed by a national ED practice group in 18 states.

RESULTS

Average monthly ED volumes fell in the early pandemic, partially recovered in 2022, but remained below 2019 levels (915 per ED in 2019 to 826.6 in 2022 for admitted patients; 3,026.9 to 2,478.5 for discharged patients). The proportion of visits assessed as critical care increased from 7.9% in 2019 to 11.0% in 2022, whereas the number of visits decreased (318,802 to 264,350). Visits billed as 99285 (the highest-acuity Evaluation and Management code for noncritical care visits) increased from 35.4% of visits in 2019 to 40.0% in 2022, whereas the number of visits decreased (1,434,454 to 952,422). Median and median of 90th percentile length of stay for admitted patients rose 32% (5.2 to 6.9 hours) and 47% (11.7 to 17.4 hours) in 2022 versus 2019. Patients leaving without treatment rose 86% (2.9% to 5.4%). For admitted psychiatric patients, the 90th percentile length of stay increased from 20 hours to more than 1 day.

CONCLUSION

ED visit volumes fell early in the pandemic and have only partly recovered. Despite lower volumes, ED crowding has increased. This issue is magnified in psychiatric patients.

Efficacy of AI Chats to Determine an Emergency: A Comparison Between OpenAI's ChatGPT, Google Bard, and Microsoft Bing AI Chat

Background The escalating overload and saturation of emergency services, primarily caused by non-urgent cases overwhelming the system, have spurred a critical necessity for innovative solutions that can effectively differentiate genuine emergencies from situations that could be managed through alternative means, such as using AI chatbots. This study aims to evaluate and compare the accuracy in differentiating between a medical emergency and a non-emergency of three of the most popular AI chatbots at the moment. Methods In this study, patient questions from the online forum r/AskDocs on Reddit were collected to determine whether their clinical cases were emergencies. A total of 176 questions were reviewed by the authors, with 75 deemed emergencies and 101 non-emergencies. These questions were then posed to AI chatbots, including ChatGPT, Google Bard, and Microsoft Bing AI, with their responses evaluated against each other and the authors' responses. A criteria-based system categorized the AI chatbot answers as "yes," "no," or "cannot determine." The performance of each AI chatbot was compared in both emergency and non-emergency cases, and statistical analysis was conducted to assess the significance of differences in their performance. Results In general, AI chatbots considered around 12-15% more cases to be an emergency than reviewers, while they considered a very low number of cases as non-emergency compared to reviewers (around 35% fewer cases). Google Bard detected the most true emergency cases (87%) and true non-emergency cases (36%). However, no real difference in performance between the three AI chatbots was found in detecting true emergencies (p-value = 0.35) and non-emergency cases (p-value = 0.16).  Conclusions These AI systems require further refinement to identify emergency situations accurately, but they could potentially be an innovative tool for emergency care and improving patient outcomes. The integration of AI chatbots like ChatGPT, Google Bard, and Microsoft Bing Chat offers a promising avenue to mitigate ED strain and enhance emergency management.

Impact of Care Initiation Model on Emergency Department Orders and Operational Metrics: Cohort Study

INTRODUCTION

Emergency departments (ED) employ many strategies to address crowding and prolonged wait times. They include front-end Care Initiation and clinician-in-triage models that start the diagnostic and therapeutic process while the patient waits for a care space in the ED. The objective of this study was to quantify the impact of a Care Initiation model on resource utilization and operational metrics in the ED.

METHODS

We performed a retrospective analysis of ED visits at our institution during October 2021. Baseline characteristics were compared with Chi-square and quantile regression. We used t-tests to calculate unadjusted difference in outcome measures, including number of laboratory tests ordered and average time patients spent in the waiting room and the ED treatment room, and the time from arrival until ED disposition. We performed propensity score analysis using matching and inverse probability weighting to quantify the direct impact of Care Initiation on outcome measures.

RESULTS

There were 2,407 ED patient encounters, 1,191 (49%) of whom arrived during the hours when Care Initiation was active. A total of 811 (68%) of these patients underwent Care Initiation, while the remainder proceeded directly to the main treatment area. Patients were more likely to undergo Care Initiation if they had lower acuity and lower risk of admission, and if the ED was busier as measured by the number of recent arrivals and percentage of occupied ED beds. After adjusting for patient-specific and department-level covariates, Care Initiation did not increase the number of diagnostic laboratory tests ordered. Care Initiation was associated with increased waiting room time by 1.8 hours and longer time from arrival until disposition by 1.3 hours, but with decreased time in the main treatment area by 0.6 hours, which represents a 15% reduction.

CONCLUSION

Care Initiation was associated with a 15% reduction in time spent in the main ED treatment area but longer waiting room time and longer time until ED disposition without significantly increasing the number of laboratory studies ordered. While previous studies produced similar results with Care Initiation models accessing all diagnostic modalities including imaging, our study demonstrates that a more limited Care Initiation model can still result in operational benefits for EDs.

Emergency department crowding: an overview of reviews describing measures causes, and harms

Crowding in Emergency Departments (EDs) has emerged as a global public health crisis. Current literature has identified causes and the potential harms of crowding in recent years. The way crowding is measured has also been the source of emerging literature and debate. We aimed to synthesize the current literature of the causes, harms, and measures of crowding in emergency departments around the world. The review is guided by the current PRIOR statement, and involved Pubmed, Medline, and Embase searches for eligible systematic reviews. A risk of bias and quality assessment were performed for each review, and the results were synthesized into a narrative overview. A total of 13 systematic reviews were identified, each targeting the measures, causes, and harms of crowding in global emergency departments. Key among the results is that the measures of crowding were heterogeneous, even in geographically proximate areas, and that temporal measures are being utilized more frequently. It was identified that many measures are associated with crowding, and the literature would benefit from standardization of these metrics to promote improvement efforts and the generalization of research conclusions. The major causes of crowding were grouped into patient, staff, and system-level factors; with the most important factor identified as outpatient boarding. The harms of crowding, impacting patients, healthcare staff, and healthcare spending, highlight the importance of addressing crowding. This overview was intended to synthesize the current literature on crowding for relevant stakeholders, to assist with advocacy and solution-based decision making.

Effect of emergency physician-operated emergency short-stay ward on emergency department stay length and clinical outcomes: a case-control study

BACKGROUND

We hypothesized that an emergency short-stay ward (ESSW) mainly operated by emergency medicine physicians may reduce the length of patient stay in emergency department without expense of clinical outcomes.

METHODS

We retrospectively analysed adult patients who visited the emergency department of the study hospital and were subsequently admitted to wards from 2017 to 2019. We divided study participants into three groups: patients admitted to ESSW and treated by the department of emergency medicine (ESSW-EM), patients admitted to ESSW and treated by other departments (ESSW-Other) and patients admitted to general wards (GW). The co-primary outcomes were ED length of stay and 28-day hospital mortality.

RESULTS

In total, 29,596 patients were included in the study, and 8,328 (31.3%), 2,356 (8.9%), and 15,912 (59.8%) of them were classified as ESSW-EM, ESSW-Other and GW groups, respectively. The ED length of stay of the ESSW-EM (7.1 h ± 5.4) was shorter than those of the ESSW-Other (8.0 ± 6.2, P < 0.001) and the GW (10.2 ± 9.8, P < 0.001 for both). Hospital mortality of ESSW-EM (1.9%) was lower than that of GW (4.1%, P < 0.001). In the multivariable linear regression analysis, the ESSW-EM was independently associated with shorter ED length of stay compared with the both ESSW-Other (coefficient, 1.08; 95% confidence interval, 0.70-1.46; P < 0.001) and GW (coefficient, 3.35; 95% confidence interval, 3.12-3.57; P < 0.001). In the multivariable logistic regression analyses, the ESSW-EM was independently associated with lower hospital mortality compared with both the ESSW-Other group (adjusted P = 0.030) and the GW group (adjusted P < 0.001).

CONCLUSIONS

In conclusion, the ESSW-EM was independently associated with shorter ED length of stay compared with both the ESSW-Other and the GW in the adult ED patients. Independent association was found between the ESSW-EM and lower hospital mortality compared with the GW.

Main Features and Control Strategies to Reduce Overcrowding in Emergency Departments: A Systematic Review of the Literature

Purpose

Overcrowding is a problem that affects emergency departments (ED) all over the world; it occurs due to a disproportion between user demand and the physical, human and structural resources available. Essential prerequisites to assessing and managing the phenomenon are its accurate measurement and an understanding of its impact. The objective of this systematic review is to identify the characteristics of the problem, analyzing the proposed strategies aimed at improving patient flow, delay in services provided and overcrowding of emergency departments.

Methods

To achieve our objectives, a manual computerized search was performed in the bibliographic databases using as keywords "Emergency Department", "Overcrowding", "Emergency Room", "Emergency Service", "Emergency Unit"",Emergency Ward", "Emergency Outpatient Unit", "Emergency Hospital", "Crowding", "Mass Gathering", "Management" and "Comprehensive Health Care". Two independent reviewers analyzed abstracts, titles and full text articles for admissibility, according to the selected inclusion and exclusion criteria.

Results

The process lead to include 19 articles. It was possible to group the solutions proposed in five categories: work organization, investment in primary care, creation of new dedicated professional figures, work and structural modifications and implementation of predictive simulation models using mathematical algorithms.

Conclusion

The most effective measures to guarantee an improvement in the flow of patients are represented by both improving the efficiency of human resources and by developing predictive mathematical models, regardless of the type of hospital and its location. Considering the complexity of EDs and the multiple characteristics of overcrowding and that the causes of crowding are different and site-specific, a careful examination of the specifics of each ED is necessary to identify improving fields.

Characteristics of First Nations patients who take their own leave from an inner-city emergency department, 2016-2020

OBJECTIVE

Using a strength-based framework, we aimed to describe and compare First Nations patients who completed care in an ED to those who took their own leave.

METHODS

Routinely collected adult patient data from a metropolitan ED collected over a 5-year period were analysed.

RESULTS

A total of 6446 presentations of First Nations patients occurred from 2016 to 2020, constituting 3% of ED presentations. Of these, 5589 (87%) patients waited to be seen and 857 (13%) took their own leave. Among patients who took their own leave, 624 (73%) left not seen and 233 (27%) left at own risk after starting treatment. Patients who were assigned a triage category of 4-5 were significantly more likely to take their own leave (adjusted odds ratio [OR] 3.17, 95% confidence interval [CI] 2.67-3.77, P < 0.001). Patients were significantly less likely to take their own leave if they were >60 years (adjusted OR 0.69, 95% CI 1.01-1.36, P = 0.014) and had private health insurance (adjusted OR 0.61, 95% CI 0.45-0.84, P < 0.001). Patients were more likely to leave if they were women (adjusted OR 1.17, 95% CI 1.01-1.36, P = 0.04), had an unknown housing status (adjusted OR 1.76, 95% CI 1.44-2.15, P < 0.001), were homeless (adjusted OR 1.50, 95% CI 1.22-1.93, P < 0.001) or had a safety alert (adjusted OR 1.60, 95% CI 1.35-1.90, P < 0.001).

CONCLUSION

A lower triage category is a strong predictor of First Nations patients taking their own leave. It has been documented that First Nations patients are under-triaged. One proposed intervention in the metropolitan setting is to introduce practices which expediate the care of First Nations patients. Further qualitative studies with First Nations patients should be undertaken to determine successful approaches to create equitable access to emergency healthcare for this population.

Overcrowding in Emergency Department: Causes, Consequences, and Solutions—A Narrative Review

Overcrowding in Emergency Departments (EDs) is a phenomenon that is now widespread globally and causes a significant negative impact that goes on to affect the entire hospital. This contributes to a number of consequences that can affect both the number of resources available and the quality of care. Overcrowding is due to a number of factors that in most cases lead to an increase in the number of people within the ED, an increase in mortality and morbidity, and a decrease in the ability to provide critical services in a timely manner to patients suffering from medical emergencies. This phenomenon results in the Emergency Department reaching, and in some cases exceeding, its optimal capacity. In this review, the main causes and consequences involving this phenomenon were collected, including the effect caused by the SARS-CoV-2 virus in recent years. Finally, special attention was paid to the main operational strategies that have been developed over the years, strategies that can be applied both at the ED level (microlevel strategies) and at the hospital level (macrolevel strategies).