Emergency department crowding: a national data report
Article information
Emergency department (ED) crowding is a significant concern that challenges healthcare systems worldwide [1–5]. It is not merely an inconvenience, but a complex issue with profound implications for patient outcomes, healthcare providers, and the overall functioning of hospitals [6,7]. ED crowding may be linked to delayed care, increased patient morbidity and mortality, medical errors, and dissatisfaction with care [2,3,8–18]. It can also place considerable strain on healthcare providers, leading to burnout and reduced quality of care.
To provide current epidemiological data on ED crowding in Korea, we conducted a retrospective analysis of data collected from the National Emergency Department Information System from 2018 to 2022 [19]. We included data from 172 EDs categorized as level I (n=40) or level II (n=132) facilities across Korea.
We evaluated ED crowding using the ED occupancy rate of the number of patients present in the ED at the time of each patient’s arrival to the total number of available beds in the ED [8,20]. Patients whose data were incomplete or missing were excluded.
ED OCCUPANCY RATE
After excluding 18,629 cases with incomplete data, a total of 25,905,347 ED visits (men, 50.7%) was analyzed. The distribution of the ED occupancy rate is shown in Fig. 1. The median ED occupancy rate of all patients was 56.5% (interquartile range [IQR], 33.3%–85.2%), and the occupancy rates for level I and level II EDs were 72.7% (IQR, 50.0%–100.0%) and 47.8% (IQR, 28.0%–76.2%), respectively (Fig. 2). The mean ED occupancy rate of all patients was 63.2%±39.4%, and the occupancy rates for level I and level II EDs were 79.8%±42.1% and 55.2%±35.4%, respectively. Approximately 15.4% of all patients visited the ED during times of overcapacity (when the ED occupancy rate exceeded 100%), and 24.6% and 11.1% of patients arrived at level I and level II EDs, respectively, during overcapacity.
Distribution of emergency department (ED) occupancy rates in Korea from 2018 to 2022.
Box plots of the emergency department (ED) occupancy rate according to the level of emergency center in Korea from 2018 to 2022.
The proportion of patients with an ED length of stay (LOS) exceeding 24 hours was 1.5% in the overall group and 2.0% and 1.2% in those at level I and level II EDs, respectively. The proportion of patients with an LOS longer than 24 hours (4.6%) was significantly higher when the ED occupancy rate exceeded 100% compared to when it did not (level I, 4.4% vs. 1.2%; level II, 4.9% vs. 0.7%; chi-square test, P<0.001 for all comparisons). The mean ED LOS for patients who arrived when the ED occupancy rate exceeded 100% was 6.4±16.6 hours, which was significantly longer compared with 3.2±7.2 hours for patients who arrived when the ED occupancy rate was less than 100% (Student t-test, P<0.001).
DISCUSSION
The current findings indicate that ED crowding remains a persistent issue in EDs in Korea, particularly in higher level facilities. Notably, nearly one in seven patients arrived at an ED when the number of patients already present exceeded the number of available beds. Ongoing challenges include efficiently managing patient flow, maintaining quality of care, and mitigating harmful effects on both patients and healthcare providers within Korea’s current emergency care system.
Various factors contribute to ED crowding, including limited hospital capacity, delays in admissions or transfers, excessive visits by low-acuity patients, inadequate staffing levels, and lack of access to primary care [1,6,7,21]. However, ED crowding is not just a hospital-specific problem, but also reflects challenges within the national healthcare system. Efforts to reduce the harmful effects of ED crowding must involve coordinated actions at both the national and hospital levels [6,7,20,22,23]. National policies and healthcare system reforms should address systemic issues, and hospitals need to implement strategies to improve patient flow, resource allocation, and appropriate staffing.
In our report, ED crowding was assessed using the ED occupancy rate; however, evaluating ED crowding solely based on bed capacity or staffing might be insufficient. Monitoring patient acuity, staffing levels, and real-time data on hospital capacity must be integrated into daily operations to limit surges in ED crowding. In the future, advanced technologies such as artificial intelligence could be applied to create a more efficient emergency care system.
The occupancy rate of level I EDs exceeded that of level II EDs, largely due to patients gravitating toward higher level hospitals in larger cities [4,24]. This contributes to overcrowding in major hospitals and highlights the need for reforms in the emergency medical system. Furthermore, this report does not address ED crowding based on regional factors [25]. Given Korea’s imbalanced distribution of population and medical facilities, with patients often bypassing local hospitals in favor of urban centers, a regional analysis of ED occupancy rates is essential. Therefore, further research and analysis on regional ED crowding are necessary.
The emergency care system in Korea is facing challenges beyond the shortage of beds. There has been a growing trend of fewer applicants for emergency medicine residencies, as observed in the United States, with an overall decline in preference among physicians for working in the ED [26]. This issue has been further aggravated by the recent resignations of many medical residents and the leaves of absence taken by medical students following the government’s 2024 decision to increase greatly the number of physicians [27]. These issues raise concerns that staffing shortages could worsen, potentially leading to emergency patients not receiving appropriate or timely care. This is another aspect of ED crowding, highlighting the need for urgent and comprehensive changes in the healthcare system.
Notes
Ethics statement
This study was approved by the Institutional Review Board of the Korean National Emergency Medical Center (No. NMC-2023-08-094). The requirement for informed consent was waived due to the retrospective, observational, and anonymous nature of the study.
Conflicts of interest
Taerim Kim and Tae Gun Shin are Editorial Board members of Clinical and Experimental Emergency Medicine, but were not involved in the peer reviewer selection, evaluation, or decision process of this article. The authors have no other conflicts of interest to declare.
Funding
The authors received no financial support for this study.
Acknowledgments
The authors thank Minyoung Choi and Doyeop Kim (Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea) for their assistance with data processing and analysis.
Data availability
Data analyzed in this study are from the National Emergency Medical Center (NEMC; Seoul, Korea), under the Korean Ministry of Health and Welfare (No. N2023-07-0-09-09). The data are not publicly accessible, as they were used under license for this study. However, they are available from the corresponding author upon reasonable request, with permission from the NEMC.