Emergency department crowding: Old problem, new solutions

In the 1990s, United States emergency departments (EDs) experienced explosive growth in patient visits, concurrent with a sharp decline in the number of hospital EDs. According to data from the National Hospital Ambulatory Medical Care Survey, annual ED visit volume rose 27% from 89.8 million to 113.9 million between 1992 and 2003 [1,2]. At the same time, the number of EDs fell 22%, from 5169 in 1988 to 4037 in 2002 [3]. Fig. 1 illustrates these trends. Over 15 years, the simple arithmetic demonstrates the basis for ED crowding. Although ED crowding is clearly related to ED volume, an ED can be busy without being crowded. Crowding refers to a condition when the needs of the patients in the ED (and patients in the waiting room) exceed the capacity of the department. Crowding is a function of patient volume, patient acuity, physical space, and on-duty staff. With increasing attention being paid to EDs as a vital component of the nation's health care safety net [4-7], ED crowding has moved to the top of the policy agenda in emergency medicine.