Executive Summary: Interventions to Improve Quality in the Crowded Emergency Department
ACADEMIC EMERGENCY MEDICINE 2011; 18:1229–1233 © 2011 by the Society for Academic Emergency Medicine Emergency department (ED) crowding is a major public health problem in the United States, with increasing numbers of ED visits, longer lengths of stay in the ED, and the common practice of ED boarding. In the next several years, several measures of ED crowding will be assessed and reported on government websites. In addition, with the implementation of the Affordable Care Act (ACA), millions more Americans will have health care insurance, many of whom will choose the ED for their care. In June 2011, a consensus conference was conducted in Boston, Massachusetts, by the journal Academic Emergency Medicine entitled “Interventions to Assure Quality in the Crowded Emergency Department.” The overall goal of the conference was to develop a series of research agendas to identify promising interventions to safeguard the quality of emergency care during crowded periods and to reduce ED crowding altogether through systemwide solutions. This was achieved through three objectives: 1) a review of interventions that have been implemented to reduce crowding and summarize the evidence of their effectiveness on the delivery of emergency care; 2) to identify strategies within or outside of the health care setting (i.e., policy, engineering, operations management, system design) that may help reduce crowding or improve the quality of emergency care provided during episodes of ED crowding; and 3) to identify the most appropriate design and analytic techniques for rigorously evaluating ED interventions designed to reduce crowding or improve the quality of emergency care provided during episodes of ED crowding. This article describes the background and rationale for the conference and highlights some of the discussions that occurred on the day of the conference. A series of manuscripts on the details of the conference is presented in this issue of Academic Emergency Medicine.
Executive Summary: Interventions to Improve
Quality in the Crowded Emergency
Jesse M. Pines, MD, MBA, MSCE, and Melissa L. McCarthy, ScD
Emergency department (ED) crowding is a major public health problem in the United States, with
increasing numbers of ED visits, longer lengths of stay in the ED, and the common practice of ED
boarding. In the next several years, several measures of ED crowding will be assessed and reported on
government websites. In addition, with the implementation of the Affordable Care Act (ACA), millions
more Americans will have health care insurance, many of whom will choose the ED for their care. In
June 2011, a consensus conference was conducted in Boston, Massachusetts, by the journal Academic
Emergency Medicine entitled ‘‘Interventions to Assure Quality in the Crowded Emergency Department.’’
The overall goal of the conference was to develop a series of research agendas to identify promising
interventions to safeguard the quality of emergency care during crowded periods and to reduce ED
crowding altogether through systemwide solutions. This was achieved through three objectives: 1) a
review of interventions that have been implemented to reduce crowding and summarize the evidence of
their effectiveness on the delivery of emergency care; 2) to identify strategies within or outside of the
health care setting (i.e., policy, engineering, operations management, system design) that may help
reduce crowding or improve the quality of emergency care provided during episodes of ED crowding;
and 3) to identify the most appropriate design and analytic techniques for rigorously evaluating ED
interventions designed to reduce crowding or improve the quality of emergency care provided during
episodes of ED crowding. This article describes the background and rationale for the conference and
highlights some of the discussions that occurred on the day of the conference. A series of manuscripts
on the details of the conference is presented in this issue of Academic Emergency Medicine.
ACADEMIC EMERGENCY MEDICINE 2011; 18:1229–1233 ª 2011 by the Society for Academic
mergency department (ED) crowding has been
identiﬁed by the Institute of Medicine (IOM) as a
public health problem.
ED crowding is caused
by episodes of supply–demand mismatch within EDs that
result in long waiting times to be seen, for critical treat-
ments, and for inpatient bed placement. Over the past 10
to 20 years, there has been an increase in waiting times
across U.S. EDs, even for patients with time-sensitive
conditions such as acute myocardial infarction.
crowding leads to less timely care and lower patient sat-
isfaction with the health care experience;
recent studies have found that crowding has a negative
effect on critical outcomes, such as complication rates
Solutions are needed at the ED, hospital,
community, and national policy levels to reduce crowd-
ing and mitigate the effects of crowding on quality and
To date, there is a paucity of rigorously
designed studies that have tested interventions to reduce
crowding and its negative effect on patient safety.
In June 2011, a consensus conference titled ‘‘Inter-
ventions to Improve Quality in the Crowded Emergency
Department’’ was conducted in Boston, Massachusetts,
ª 2011 by the Society for A cademic Emergency Medici ne ISSN 1069-6563
doi: 10.1111/j .1553-2712.2 011.01228.x PII ISSN 1069- 6563583 1229
From the Departments of Emergency Medicine and Health Policy, George Washington University, Washington, DC.
Received July 14, 2011; accepted July 29, 2011.
Funding for this conference was made possible (in part) by 1R13HS020139-01 from the Agency for Healthcare Research and Quality
(AHRQ). The views expressed in written conference materials or publications and by speakers and moderators do not necessarily
reﬂect the ofﬁcial policies of the Department of Health and Human Services, nor does mention of trade names, commercial prac-
tices, or organizations imply endorsement by the U.S. Government. This issue of Academic Emergency Medicine is funded by the
Robert Wood Johnson Foundation.
The authors have no relevant ﬁnancial information or potential conﬂicts of interest to disclose.
Supervising Editor: James Miner, MD.
Address for correspondence and reprints: Jesse M. Pines, MD, MBA, MSCE; e-mail: firstname.lastname@example.org.
and sponsored by the journal Academic Emergency
Medicine. Drs. Jesse M. Pines and Melissa L. McCarthy
served as conference co-chairs, and many of the after-
noon group sessions were led by members of the Soci-
ety for Academic Emergency Medicine Crowding
Interest Group. The overall goal of the conference was
to develop a series of research agendas to identify
promising interventions to safeguard the quality of
emergency care during crowded periods and reduce
ED crowding altogether through systemwide solutions.
The goal was achieved through three objectives. The
ﬁrst was a review of interventions that have been
implemented to reduce crowding and summarize the
evidence of their effectiveness on the delivery of emer-
gency care. The second was to identify strategies within
or outside of the health care setting (policy, engineer-
ing, operations management, system design, etc.) that
may help reduce crowding or improve the quality of
emergency care provided during episodes of ED
crowding. The third objective was to identify the most
appropriate design and analytic techniques for rigor-
ously evaluating ED interventions designed to reduce
crowding or improve the quality of emergency care
provided during episodes of crowding. This issue of
Academic Emergency Medicine contains detailed
descriptions of the conference proceedings and
includes the six research agendas developed surround-
ing the six IOM quality domains: efﬁciency, effective-
ness, timeliness, patient-centeredness, safety, and
equity. This article provides a justiﬁcation for the meet-
ing and then brieﬂy summarizes some of the key con-
cepts that are described in detail in the rest of this
SCIENTIFIC NEED FOR THE MEETING
The causes of ED crowding have been well described.
One reason for crowding is the increase in demand for
ED services. Between 1995 and 2005, ED utilization
increased nationally by 20% from 97 to 115 million vis-
In addition, increased demand also includes a
higher severity of patients in the ED who require more
services. This is partially driven by increasing numbers
of older adults coming to EDs with larger numbers of
chronic medical conditions, an increased complexity of
illness, and higher levels of technology that are avail-
able for routine use (like computed tomography, mag-
netic resonance imaging, and other advanced testing
A second reason for crowding is
related to supply. Increased demand for ED services
has been commensurate with a reduction in the number
of EDs and hospitals; however, it is unknown whether
overall ED bed capacity has been shrinking, because
many EDs have expanded in the past several years.
A recent study found that 27% of nonrural EDs have
closed over the past 20 years, indicating that clearly the
number of EDs is reduced.
Insufﬁcient inpatient bed
capacity in the hospital, which leads to boarding (where
patients spend long periods of time waiting in the ED
for inpatient beds) results in lower ED capacity for
new, undifferentiated patients.
Some of the boarding
problems may be caused by artiﬁcial variation in bed
demand that occurs due to the elective procedure
schedule that can coincide with high, daily demand for
inpatient beds from ED patients.
In her comments
during the moderated panel, Dr. Sandra Schneider, the
president of the American College of Emergency Physi-
cians, highlighted the importance of reducing boarding
as the key to reducing ED crowding and the need to
communicate with outside stakeholders that boarding
is a lead driver of ED crowding.
There are many factors that can inﬂuence patient
ﬂow and the overall quality of care provided in EDs.
Some of the factors are intrinsic to the ED, such as
access to on-call specialists, the use of decision support
tools, stafﬁng levels, and experience and training of ED
providers. Emergency care is also heavily inﬂuenced by
external forces from the hospital and surrounding com-
munity. Hospital factors such as inpatient bed capacity
strategies, electronic information systems that are fully
integrated across all inpatient and outpatient services,
policies that incentivize quality and optimal patient out-
comes, and community factors, particularly the avail-
ability of primary and specialty care, all inﬂuence the
quality of care provided in the ED. Therefore, the effec-
tiveness of an ED depends on its success in dealing
with major organizational challenges including coordi-
nation and control of work efforts, availability and
proper allocation of professional and other resources,
maintenance of suitable work arrangements, and
adaptation to the external environment.
Emergency departments must learn how to operate
more efﬁciently, to use information technologies to sup-
port process management, and to employ high reliability
design principles that result in the routine provision of
high-quality care. Until recently, the health care system
(and particularly EDs) has not looked to other industries
for potential strategies that may improve service deliv-
ery. A key component of the conference was to discuss
how well-tested strategies and management principles
from other industries apply to the ED. This was done by
bringing together leading ED crowding researchers and
managers with professionals who have experience
applying operations principles to quality improvement
to propose a series of research agendas for the specialty
centered around patient ﬂow and quality.
MOVING FROM CAUSES AND CONSEQUENCES TO
Emergency medicine as a specialty ﬁnds itself at a simi-
lar point in time to that of anesthesia 20 years ago. At
that time, many patients were suffering from anesthe-
sia-related mishaps because of a poorly designed sys-
tem. Although ED patients are not dying in great
numbers, they are experiencing signiﬁcant delays in
evaluation and treatment for emergent and urgent con-
ditions because of the same reason: a poorly designed
system. To improve the quality of anesthesia care, the
specialty borrowed heavily from techniques and lessons
learned in the aviation industry and created basic stan-
dards for monitoring during anesthesia. In his com-
ments during the lunchtime panel, Dr. Peter Viccellio,
Vice Chair of Emergency Medicine at SUNY Stony-
brook, described how emergency medicine should
focus the conversation about crowding on patient
Pines and McCarthy
2011 CC EXECUTIVE SUMMARY
safety and identifying solutions within the ED rather
than complaining that external forces need to ﬁx the
However, despite the need for operational improve-
ments in the delivery of ED care, there have been rela-
tively few rigorous evaluations of operational
interventions in the ED setting. Many EDs have tried
interventions such as immediate bedding, bedside reg-
istration, physician at triage, advanced triage protocols,
inpatient bed capacity protocols, and point-of-care test-
ing to improve operational efﬁciency.
tions that have been tried have not been carefully
designed and evaluated, so their value remains unclear.
It is not currently known which interventions are most
effective, so it can be a challenge for ED managers and
policy-makers to choose where to invest time and
energy. The keynote speaker, Dr. Suzanne Mason, a
Professor of Emergency Medicine at the University of
Shefﬁeld in the United Kingdom, described the enor-
mous energy and resources spent implementing the
U.K. 4-hour rule, its unintended consequences, and the
recent decision to abolish it.
The UK has learned a
tremendous amount about improving the quality of
emergency care through the implementation of the
4-hour rule, but it came at a high cost.
Another challenge for improving ED operations is
that strategies may be successfully implemented in
some environments and not in others. In his comments
during the lunchtime panel, Dr. Randy Pilgrim, the
Chief Medical Ofﬁcer of the Schumacher Group,
described several situations where similar interventions
were implemented at different hospitals with varied
success, and the major success factors were the ED
leadership and the buy-in from hospital management.
This was also echoed by Dr. Bruce Siegel, who
described the work of Urgent Matters, a multiyear ED
quality improvement project aimed at improving ﬂow.
Dr. Siegel highlighted the importance of objective mea-
surement and the role of senior management in suc-
cessful throughput improvement interventions.
One of the objectives of the conference was also to
emphasize the importance of rigorous operations
research in the ED setting and to encourage EDs to
embrace a process of continual evaluation and
improvement that acknowledges the important role of
leadership and management in any quality improve-
ment intervention. Bringing in other outside disciplines
and the ﬁelds of organizational behavior and industrial
psychology may be helpful in improving our under-
standing of the leadership and teamwork required for
Several sessions in the meeting served to stimulate
ED clinicians, administrators, and researchers to think
boldly and innovatively about improving the quality of
emergency care. For example, Dr. Christian Terwiesch,
a Professor of Operations Management at the Wharton
School, presented a basic vocabulary for operations
research and proposed that through operations
research principles, three basic levers can be used to
improve crowding: eliminating waste, reducing vari-
ability, and improving ﬂexibility.
This provided a
framework for how to conceptualize ED crowding
interventions. Most operational research to date has
focused on relatively small process changes to the exist-
ing system, rather than proposing fundamental changes
to care delivery systems. For example, one way to
reduce waste is to standardize emergency care by
adopting the well-validated clinical decision rules that
have been developed for emergency medicine.
The conference explored engineering and operations
management strategies for reducing crowding and
improving quality of care. Dr. Michael Carter, a Profes-
sor of Mechanical and Industrial Engineering at Univer-
sity of Toronto, discussed the use of computer simulation
for forecasting and applying demand-capacity manage-
ment strategies. Dr. Terwiesch talked about the
importance of designing systems and work processes
that better match supply and demand.
Dr. Brad Morrison, Assistant Professor of Manage-
ment at Brandeis University; Dr. Jenny Rudolph, Assis-
tant Professor in Anesthesiology and Critical Care
Medicine at Harvard Medical School; and Dr. Gordon
Schiff, Associate Professor of Internal Medicine at
Harvard Medical School, discussed the role of systems
dynamics in understanding complex systems, the need
for incorporating high reliability design principles into
our work environment, and the use of decision theory
and measurement of workload and organizational per-
formance to improve the quality of emergency care.
Another focus of the conference was policy interven-
tions that can improve the quality of emergency care.
Dr. Howard Ovens, Associate Professor in the Depart-
ment of Family and Community Medicine at the Univer-
sity of Toronto, and Dr. John Heyworth, the president
of the College of Emergency Medicine in England, dis-
cussed policy solutions to ED crowding in the United
Canada has implemented a
pay-for-performance initiative to incentivize hospitals in
Ontario to reduce ED length of stay as part of a com-
prehensive approach to improving emergency ﬂow that
involves all sectors of the health care system. Although
these policy interventions have been implemented in
countries with a national health care system, there are
still many lessons to learn from them regarding their
potential effect if employed in the United States.
Finally, the conference also covered methodologic
issues that are important to the proper conduct of oper-
ations research in emergency medicine. Drs. McCarthy
and Pines discussed different methods for measuring
crowding, how to evaluate the quality of emergency
care, and quasi-experimental study designs that are
appropriate when randomized controlled trials are not
Dr. McCarthy discussed the importance of
trying interventions on a small scale ﬁrst, not being
afraid to fail because much is learned through failure,
and the need for journals in our specialty to support
the publications of small scale and ⁄ or negative quality
improvement studies because we need a medium to
learn from each other’s efforts and foster future
research in this area.
The afternoon sessions of the conference focused on
developing a series of research agendas to identify
promising strategies to improve the quality of emer-
gency care in all six IOM domains. Each of the domains
was led by an individual with expertise in the ﬁeld who
worked to frame the issue of safeguarding the quality
ACADEMIC EMERGENCY MEDICINE
December 2011, Vol. 18, No. 12
of emergency care during ED crowding in the context
of that particular IOM domain and then created a series
of prioritized questions that represented the next logi-
cal steps to move forward the state of science for the
particular domain. For example, the safety group,
which was led by Dr. Christopher Fee, Associate Pro-
fessor of Emergency Medicine at the University of
California at San Francisco, divided the questions into
basic science (e.g., what are the best measures for ED
patient safety?) and applied science (e.g., do checklists
improve ED safety at more crowded times?).
larly, Dr. Michael Ward, an Operations Research Fellow
and Assistant Professor of Emergency Medicine at the
University of Cincinnati, posed some fundamental ques-
tions, such as what measures can be used to under-
stand and improve the efﬁciency in the ED and which
interventions related to technology, structure, and
design effect ED efﬁciency.
Detailed research agendas
are published in this issue of Academic Emergency
THE ROAD AHEAD
The June 2011 conference and the resultant publica-
tions in this issue of Academic Emergency Medicine
moved the conversation forward on ED crowding inter-
ventions by bringing together diverse disciplines
around a central goal, fostered serious discussion on
the practicalities and challenges of operational research
in emergency medicine, and framed the next important
questions that should be answered to inform the work
of hospitals, policy-makers, and researchers in the com-
ing years. This conference came at a vital time in the
development of emergency care in the United States. It
is a time when there will be not only a greater focus on
quality and throughput, as several of the measures of
ED crowding and ﬂow become national quality mea-
sures, but also at a time when the changes in insurance
coverage through the Affordable Care Act are just
about to be implemented, which will make 30 million
more Americans insured by Medicaid. It is our hope
that the discussions, research questions, and collabora-
tions that come out of this conference will contribute to
the reduction of crowding and the improvement of the
quality of emergency care in this country and
1. Institute of Medicine. Hospital-based Emergency
Care: At the Breaking Point. Washington, DC:
National Academies Press, 2006.
2. Wilper AP, Woolhandler S, Lasser KE, et al. Waits
to see an emergency department physician: U.S.
trends and predictors, 1997-2004. Health Aff (Mill-
wood). 2008; 27:w84–95.
3. Horwitz LI, Bradley EH. Percentage of US emer-
gency department patients seen within the recom-
mended triage time: 1997 to 2006. Arch Intern Med.
4. McCarthy ML, Zeger SL, Ding R, et al. Crowding
delays treatment and lengthens emergency
department length of stay, even among high acuity
patients. Ann Emerg Med. 2009; 54:492–503.
5. Pines JM, Iyer S, Disbot M, Hollander JE, Shofer
FS, Datner EM. The effect of emergency depart-
ment crowding on patient satisfaction for admitted
patients. Acad Emerg Med. 2008; 15:825–31.
6. Pines JM, Pollack CV Jr, Diercks DB, et al. The
association between emergency department crowd-
ing and adverse cardiovascular outcomes in
patients with chest pain. Acad Emerg Med. 2009;
7. Chalﬁn DB, Trzeciak S, Likourezos A, et al. Impact
of delayed transfer of critically ill patients from the
emergency department to the intensive care unit.
Crit Care Med. 2007; 35:1477–83.
8. Guttmann A, Schull MJ, Vermeulen MJ, Stukel TA.
Association between waiting times and short term
mortality and hospital admission after departure
from emergency department: population based
cohort study from Ontario, Canada. BMJ. 2011;
9. Hoot NR, Aronsky D. Systematic review of emer-
gency department crowding: causes, effects, and
solutions. Ann Emerg Med. 2008; 52:126–36.
10. Pitts SR, Niska RW, Xu J, Burt CW. National Hospi-
tal Ambulatory Medical Care Survey: 2006 emer-
gency department summary. Natl Health Stat
Report. 2008; 7:1–38.
11. Peters ML. The older adult in the emergency
department: aging and atypical illness presentation.
J Emerg Nurs. 2010; 36:29–34.
12. Pines JM. Trends in the rates of radiography use
and important diagnoses in emergency department
patients with abdominal pain. Med Care. 2009;
13. Hsia RY, Kellermann AL, Shen YC. Factors associ-
ated with closures of emergency departments in the
United States. JAMA. 2011; 305:1978–85.
14. Bullard MJ, Villa-Roel C, Bond K. Tracking emer-
gency department overcrowding in a tertiary care
academic institution. Healthc Q. 2009; 12:99–106.
15. Pines JM, Batt RJ, Hilton JA, Terwiesch C. The
ﬁnancial consequences of lost demand and reducing
boarding in hospital emergency departments. Ann
Emerg Med. 2011; 58:331–40.
16. Rathlev NK, Chessare J, Olshaker J, et al. Time ser-
ies analysis of variables associated with daily mean
emergency department length of stay. Ann Emerg
Med. 2007; 49:265–71.
17. Pines JM, Pilgrim RL, Schneider SM, Siegel B,
Vicciello P. Practical implications of implementing
emergency department crowding interventions:
summary of a moderated panel. Acad Emerg Med.
18. Wiler JL, Gentle C, Halfpenny JM, et al. Optimizing
emergency department front-end operations. Ann
Emerg Med. 2010; 55:142–60.
19. Mason S. United Kingdom experiences of evaluating
performance and quality in emergency medicine.
Acad Emerg Med. 2011; 18:1234–1238.
20. Soremekun OA, Terwiesch C, Pines JM. Emergency
medicine: an operations management view. Acad
Emerg Med. 2011; 18:1262–1268.
Pines and McCarthy
2011 CC EXECUTIVE SUMMARY
21. Morrison JB, Rudolph JW. Learning from accident
and error: avoiding the hazards of workload, stress,
and routine interruptions in the emergency depart-
ment. Acad Emerg Med. 2011; 18:1246–1254.
22. Schiff GD. System dynamics and dysfunctionalities:
levers for overcoming emergency department over-
crowding. Acad Emerg Med. 2011; 18:1255–1261.
23. Ovens H. Emergency department overcrowding:
the Ontario Approach. Acad Emerg Med. 2011;
24. Heyworth J. Emergency medicine—quality indica-
tors: the United Kingdom perspective. Acad Emerg
Med. 2011; 18:1239–1241.
25. McCarthy ML, Ding R, Pines JM, Zeger SL. Com-
parison of methods for measuring crowding and its
effects on length of stay in the emergency depart-
ment. Acad Emerg Med. 2011; 18:1269–1277.
26. Fee C, Hall K, Morrison JB, et al. Consensus-based
recommendations for research priorities related to
interventions to safeguard patient safety in the
crowded emergency department. Acad Emerg Med.
27. Ward MJ, Farley H, Khare RK, et al. Achieving efﬁ-
ciency in crowded emergency departments: a
research agenda. Acad Emerg Med. 2011;
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