Objective To quantify the extent to which time-based and operational factors drive emergency department (ED) overcrowding and evaluate the impact of targeted process improvements without constructing a new composite index.
Methods We conducted a single-center, retrospective before–after study of 6,881 adults with high triage acuity (Korean Triage and Acuity Scale levels 1–3) who were admitted from the ED across two consecutive 12-month periods: period 1 (2021-07-01 to 2022-06-30) and period 2 (2022-07-01 to 2023-06-30). Interventions were launched hospital-wide, targeting consultation responsiveness, earlier admission decision-making, faster ward bed assignment, and post-assignment transport and handover, which were implemented concurrently. The primary outcome was the change in ED length of stay (LOS; arrival-to-ED exit), and the secondary outcomes were changes in five key interval times along the care pathway.
Results The Mean ED LOS decreased significantly from 424.8±471.3 minutes to 283.2±306.9 minutes (–141.6 minutes, approximately 33% reduction; p<0.05). All interval means improved significantly (all p<0.05); notably, the 'admission decision-to-ED exit' interval shortened from 173.3±295.2 to 84.7±118.4 min. Improvements were consistent across all the high-acuity strata.
Conclusion Targeted pathway-level process improvements, especially those that shorten boarding, substantially reduced ED LOS and relieved overcrowding among admitted highacuity patients. A boarding-focused, hospital-wide approach is an operationally transferable framework for institutions that cannot implement composite crowding indices owing to data limitations although attribution to specific components requires more granular study designs.
Objective Ambulance offload delays and emergency department [ED] crowding worsened during COVID-19 and remain critical in Victoria, where <62 % of ambulances offload on time. Evidence on post-pandemic trends is limited. We analysed offload delays and ED length of stay [LOS] at a major Melbourne health service [Jan 2018–Aug 2024] across three periods: pre-COVID, during COVID and post-COVID, stratified by admission status.
Methods Monthly median offload times and ED LOS were examined using interrupted time-series models to detect level and slope changes.
Results Among 529 261 presentations, median offload times for non-admitted patients increased 12.7 min at the post-COVID transition then fell 0.62 min per month, ending below pre-COVID projections. Admitted patients showed a median 14.2 min increase and a 0.73 min per month decline. ED LOS median time rose post-COVID by 53.6 min for non-admitted and 124.8 min for admitted patients. Thereafter, non-admitted patient LOS declined, whereas admitted patient LOS remained persistently elevated and stabilised at a high level.
Conclusions Although ambulance offload delays have improved, now below pre-COVID counterfactual levels, emergency department length of stay remains elevated particularly for admitted patients. Targeted interventions such as dedicated offload staff, real-time bed management, and streamlined discharge pathways are needed to address persistent emergency department crowding.
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Systematic Review
Emergency Medicine Practice and Administration | Public Health & Policy
Objective This study systematically reviews the causes, effects, and potential solutions to emergency department (ED) crowding, with emphasis on challenges amplified by the COVID-19 pandemic. Methods Following PRISMA guidelines, we searched MEDLINE, CINAHL, and the Web of Science for peer reviewed studies published from January 1, 2018, to January 31, 2025, that investigated ED crowding. Studies were included if they evaluated crowding causes, consequences, or interventions, using metrics such as ED length of stay, boarding, or left without being seen. Four reviewers independently screened titles, abstracts, and full texts. Study quality was assessed using the SIGN critical appraisal tools. This review was registered in PROSPERO (No. CRD420251117676). Results Of 23,408 studies identified, 226 met inclusion criteria. Most studies were retrospective (83%) and of low (62%) or acceptable (35%) quality. Crowding was primarily driven by input (high patient volumes, limited primary care access), throughput (staffing shortages, laboratory and imaging delays), and output (boarding, late discharges) factors. Adverse effects included increased mortality, treatment delays, prolonged inpatient stays, higher rates of patients leaving without being seen, and reduced patient satisfaction. Effective strategies included provider-in-triage, nurse-initiated orders, and split-flow models. Output-focused interventions, such as active bed management and early discharge protocols, required system-wide coordination. The COVID-19 pandemic shifted patient volumes and led to innovative solutions such as drivethrough clinics and repurposed spaces to alleviate surges. Conclusion ED crowding is a persistent global issue with significant clinical and operational consequences. While promising interventions exist, high-quality evidence remains limited, underscoring the need for system-level and multifaceted solutions.
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Objective This study used a nationwide database to identify and analyze factors that influence emergency department (ED) length of stay (LOS) and improve the efficiency of emergency care. Methods This retrospective study analyzed data from the National Emergency Department Information System (NEDIS) database in Korea: 25,578,263 ED visits from 2018 to 2022. Patient demographics, clinical characteristics, and ED operational variables were examined. Univariate and multivariate logistic regression analyses were used to assess the associations between the variables and prolonged ED LOS, defined as 6 hours or more. Results Among the 25,578,263 patients, the median ED LOS was 2.1 hours (interquartile range, 1.050–3.830 hours), with 12.6% experiencing a prolonged ED LOS. Elderly patients (aged ≥65 years) were significantly more likely than younger patients to experience prolonged ED LOS (adjusted odds ratio [aOR], 1.415; 95% confidence interval [CI]: 1.411–1.419). Patients transferred from other hospitals (aOR, 1.469; 95% CI, 1.463–1.474) and those arriving by emergency medical services (aOR, 1.093; 95% CI, 1.077–1.108) also had high odds of prolonged LOS. Conversely, pediatric patients had a low likelihood of extended stay (aOR, 0.682; 95% CI, 0.678–0.686). Severe illness, including sepsis (aOR, 1.324; 95% CI, 1.311–1.340) and COVID-19 infection (aOR, 1.413; 95% CI, 1.399–1.427), was strongly associated with prolonged LOS. Conclusion Prolonged ED LOS is influenced by a combination of patient demographics, clinical severity, and systemic factors. Targeted interventions for older adults, severe illness, and operational inefficiencies such as hospital transfers are essential for reducing ED LOS and improving overall emergency care delivery.
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Objective This study aimed to evaluate the association between prehospital recognition of acute myocardial infarction (AMI) and length of stay (LOS) in the emergency department (ED) of emergency medical service (EMS)-transported AMI patients.
Methods A multicenter retrospective observational study was conducted using prehospital and hospital data from three tertiary emergency departments. Patients diagnosed with AMI between January 2015 and December 2018 were enrolled. Study groups were categorized according to prehospital recognition and prehospital 12-lead electrocardiography (ECG) into three groups based on an EMS cardiovascular registry: group A, no prehospital recognition (reference group); group B, prehospital recognition without 12-lead ECG; and group C, prehospital recognition with 12-lead ECG. The primary outcome was an ED LOS of less than 4 hours.
Results Among 1,237 study participants, 722 (58.4%) were in group A, 325 (26.3%) were in group B, and 190 (15.4%) were in group C. Multivariable logistic regression showed that groups B and C had a higher likelihood of a short ED LOS (adjusted odds ratio [95% confidence interval]: group B, 1.64 [1.21–2.22] and group C, 1.88 [1.30–2.71]) than group A. There was no significant difference in ED LOS according to whether prehospital 12-lead ECG was conducted.
Conclusion Prehospital recognition of AMI by EMS personnel, with or without 12-lead ECG, was associated with a short ED LOS.
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Objective This study aimed to evaluate the change in length of stay (LOS) in the emergency department (ED) and outcomes during the coronavirus disease 2019 (COVID-19) pandemic.
Methods This is a single-center, retrospective observational study. We compared ED LOS and outcomes in patients aged ≥19 years who presented to the ED of Soonchunhyang University Bucheon Hospital, a single tertiary university hospital, between January and December in 2018, 2019, and 2020. We included patients who were diagnosed with fever, pneumonia, and sepsis in the ED, based on the International Statistical Classification of Diseases and Related Health Problems 10th Revision. We also compared the LOS and outcomes of overall ED patients in 2019 (before COVID-19) and in 2020 (after COVID-19).
Results A total of 5,061 patients with fever, pneumonia, and sepsis were analyzed. The LOS in the ED in 2020 significantly increased compared with 2018 and 2019 (177.0±115.0 minutes in 2018, 154.0±85.0 minutes in 2019, and 208.0±239.0 minutes in 2020). The proportion of patients who were transferred to other hospitals in 2020 (2.1%) increased compared with 2018 (0.8%) and 2019 (0.7%). Intensive care unit admission significantly increased in 2020 (13.7%) compared with 2019 (10.3%). Among all ED patients, ED LOS in 2020 was longer than in 2019, particularly in patients who were admitted and then transferred to another hospital. Intensive care unit admission (4.4% vs. 5.0%), transfer rate (0.7% vs. 0.9%), and ED mortality (0.6% vs. 0.7%) also significantly increased.
Conclusion The ED LOS, time to intensive care unit admissions, time to transfer to other hospitals, and ED mortality significantly increased during the COVID-19 pandemic.
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Objective Especially in emergency departments (EDs), a lack of internal medicine (IM) residents in charge causes difficulties in medical care and ED overcrowding. Thus, protocols without IM residents in EDs is needed. This study aimed to investigate changes in medical care when emergency medicine residents replaced the roles of IM residents.
Methods This study was conducted at a single-site ED of a university medical center. The study group contained patients admitted to the IM department between September and December 2015, during which IM residents were absent in the ED. The control group contained patients admitted to the IM department between September and December 2014, during which IM residents were present in the ED. Changes in medical care between the presence and absence of IM residents in the ED were studied by comparing admission rates from the ED, length of ED stay, duration of hospitalization, and concordance of diagnoses between admission and discharge by the IM department.
Results The study group contained 2,341 patients; the control group contained 2,215 patients. Admission rates from the ED increased by 53.4% (95% confidence interval [CI], P<0.001); lengths of stay decreased by 15.1% (95% CI, P<0.001); and durations of hospitalization in the pulmonology department decreased by 38.4% (95% CI, P=0.001). Concordance of diagnoses between admission and discharge decreased by 14.2% in the cardiology department (95% CI, P=0.021).
Conclusion Lengths of stay were reduced without critical declines in diagnostic concordance rates when emergency medicine physicians, instead of IM residents in the ED, decided upon admissions of IM patients.
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Objective This study aimed to evaluate the effect of alcohol use on emergency department (ED) length of stay (LOS) among minimally injured patients by mechanism of injury. Methods This was a retrospective study of injury surveillance data for injured patients (except poisoning), aged over 18 years, discharged home from the ED, and treated at seven academic EDs in Korea during 2008 to 2012. Patients were divided into alcohol-related and alcohol-unrelated groups based on self-report. We used multivariable quantile regression models for the analysis and adjusted covariates including age, sex, consciousness status, severity of injury, emergency medical service use, the season, day and time of visit, and hospital. To determine if there were different effects of alcohol use across mechanism of injury, all analyses were stratified by each mechanism.
Results Among 192,200 patients, 95,807 patients were analyzed. The number of participants in the alcohol-related group was 16,249 (17.0%). In the multivariable quantile regression model, the alcohol-related group had significantly longer ED LOS at the 10th (7 minutes; 95% confidence interval [CI], 6 to 8), 50th (21 minutes; 95% CI, 19 to 23), and 90th (81 minutes; 95% CI, 74 to 87) percentiles when compared to the alcohol-unrelated group. The effect of alcohol use on increased ED LOS was most prominent in motor vehicle injuries.
Conclusion We found that alcohol use was associated with increased emergency ED LOS. Furthermore, if we limited our attention to the effect of alcohol use on the number of patients, the burden of alcohol use on the ED would have been underestimated.
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Objective The aim of this study was to evaluate the effect of adding bedside ultrasonography to the diagnostic algorithm for nephrolithiasis on emergency department (ED) length of stay.
Methods A prospective, randomized, controlled pilot study was conducted from October 2014 to December 2014 with patients with acute flank pain. In the non-ultrasonography group (NUSG), non-contrast computed tomography was selected based on clinical features and hematuria in the urinalysis. In the ultrasonography group (USG), non-contrast computed tomography was selected based on clinical features and hydronephrosis on bedside ultrasonography. The primary outcome was ED length of stay. The secondary outcomes were radiation exposure, amount of analgesics, proportion of patients with diseases other than ureteral calculus, and proportion of patients with unexpected ED revisits within 7 days from the index visit.
Results A total of 103 patients were enrolled (NUSG, 51; USG, 52). The ED length of stay for the USG (89.0 minutes) was significantly shorter than that for the NUSG (163.0 minutes, P<0.001). There were no significant differences between the two groups in the radiation exposure dose (5.29 and 5.08 mSv, respectively; P=0.392), amount of analgesics (P=0.341), proportion of patients with diseases other than ureteral calculus (13.0% and 6.8%, respectively; P=0.486), and proportion of patients with unexpected ED revisits within 7 days from the index visit (7.8% and 9.6%, respectively; P=1.000).
Conclusion The use of early bedside ultrasonography for patients with acute flank pain could reduce the ED length of stay without increasing unexpected ED revisits.
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Portable Ultrasound Device Usage and Learning Outcomes Among Internal Medicine Trainees: A Parallel‐Group Randomized Trial Andre Kumar, Yingjie Weng, Jason Bentley, Marta Almli, Jason Hom, Ronald Witteles, Neera Ahuja, John Kugler Journal of Hospital Medicine.2020; 15(3): 154. CrossRef
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Objective The supply of emergency medicine (EM) specialists has not been able to meet demand in the past decade. This study comparatively analyzed clinical findings to provide fundamental data to inform efficient utilization of a limited number of EM specialists.
Methods This retrospective study included 54,204 patients who visited the emergency department of a tertiary care medical center from March 1 to December 31, 2012. The experimental specialist-supervised (SS) group included patients supervised by an EM specialist, while the control specialist-on-call (SOC) group included patients attended by a senior resident of EM with an EM specialist on call.
Results The mean length of stay in the emergency department was longer in the SS group than in the SOC group for all levels of severe-to-moderate (levels 1 to 3) and mild (levels 4 and 5) patient conditions (P<0.05). The mortality rate of severe-to-moderate patients in the SOC group was 1.63 times higher than that in patient in the SS group.
Conclusion Supervision by EM specialists significantly decreased mortality in patients with severe-to-moderate condition. Therefore, EM specialists should focus on this patient group, while training residents should concentrate on patients with relatively mild conditions.
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