Emergency Department (ED) Overcrowding Leads to Worse Health Outcomes

Hospitals throughout the United States are facing increasing levels of emergency department (ED) overcrowding, an issue that Penn State researchers linked to worse health outcomes and even death.

In a recent article published in Health Services Research,  researchers examined more than five million discharge records to determine if ED overcrowding on the day of discharge impacts the patient length of stay, in-hospital mortality, and ED readmission.

ED crowding is often defined as the number of people in the department, but the researchers said issue is more complex than that; it also involves the staffing level, the number of inpatient beds available, and the complexity of cases being treated.

“Though it is understood that a lack of available inpatient beds can lead to emergency department crowding, this is the first time that research has examined whether this crowding was associated with problems throughout the hospital,” Charleen Hsuan, assistant professor of health policy and administration and lead author of the article, said in a press release.

“Since this association was just discovered, we do not know for sure what causes the increase in deaths, but the increased workload for the inpatient nurses and doctors seems to be one likely factor.” 

Between October 2015 and December 2017, nearly 2.6 percent of patients died during their inpatient stay, the researcher reported.

As ED overcrowding increased, as did the likelihood of patient mortality. When ED occupancy was above average, patients were 3.1 percent more likely to die than those treated in less crowded environments. That number rose to 3.8 percent when ED occupancy increased slightly.

When ED overcrowding reached its peak, patients were, on average, 5.4 percent more likely to die.

“We are not saying that people are dying because of emergency room crowding,” Hsuan said. “The causes of death have not been explored. What these results show, however, is that hundreds more people died every year in these hospitals when emergency departments were crowded than when emergency departments were less full. Whatever the reason or reasons, that phenomenon is clearly important to understand.” 

Many hospital administrators and policymakers see ED crowding as a problem specific to the ED, but overcrowding often stems from a lack of inpatient beds.

“One thing is clear: ED crowding is a whole-hospital problem,” Hsuan said. “When policymakers and hospital administrators think about this problem, they need to consider the impacts on all patients and not just those in the emergency department. Policymakers may need to take a systems perspective on improving the quality of care in hospitals.” 

As of the 1980s, ED overcrowding has been an issue of national concern. Since then, the problem has only gotten worse. Other studies have shown that ED overcrowding impacts more than the people who are admitted.

According to two studies, ED wait times are lengthening. In some cases, waits are over nine hours, leaving many patients without care access.

When EDs are overcrowded and wait times are long, patients are more likely to leave EDs before clinical evaluation.

Researchers found that the median rate of patients leaving the ED without being seen nearly doubled from 1.1 percent to 2.1 percent from January 2017 to December 2021, according to one study published in October 2022.

“This is not an ED management issue,” Arjun Venkatesh, an associate professor of emergency medicine at Yale School of Medicine and an author of the studies, said in a press release about the October 2022 study. “These are indicators of overwhelmed resources and symptoms of deeper problems in the healthcare system.”