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Posted: 3-27-13

Admitted patients not uncommonly spend hours and sometimes days in the emergency department (ED) waiting for a bed to open in the hospital so they can receive the care they need. These boarded patients lie and wait on gurneys in ED rooms and in hallways in a chaotic environment that threatens their safety, comfort, and outcome. As patients backup, wait times are prolonged, ambulances get diverted, patients leave without being seen by a medical professional, medical errors increase, and patient care suffers.

The Crisis of Overcrowding

According to the 2008 ACEP Task Force Report on Boarding, "Crowding is a crisis that results from the practice of "boarding" or holding emergency patients who have been admitted to the hospital in the emergency department. Crowding occurs when no inpatient beds are available in the hospital, not because of too many patients with non-urgent medical conditions seeking emergency care." Emergency department crowding is an institutional problem that goes beyond the emergency department.

Crowding is the end result of problems related to patient flow, availability of ancillary services, case management, discharge protocols and priorities, nursing management, physician oversight, and administrative support. Patients' need for services are 24/7/365, but most hospital operations function as 9 to 5, Monday through Friday institutions with skeleton crews on evenings, nights, and weekends, according to the ACEP report. This mismatch of resources is a major contributor to ED overcrowding.

Nearly 90% of surveyed ED directors indicate that overcrowding is an issue at their hospital. Over one third of the directors list overcrowding as a daily problem, and over half report that overcrowding occurs several times per week. This problem continues to grow as emergency department utilization increases. From 2001 to 2008 the number of ED visits increased yearly by 1.9% while the problem of ED overcrowding increased by 3.1% per year.

New Joint Commission Performance Standards

The Joint Commission (TJC) has also taken notice. In their performance standards that went into effect January 1, 2013, TJC is requiring hospitals to set specific goals to improve patient flow which includes the availability of patient beds and maintaining proper throughput in laboratories, operating rooms, inpatient units, telemetry, radiology, and the post-anesthesia care unit. Nonclinical areas such as housekeeping, transportation, case management, and social work are also being evaluated.  

The standards specifically name the medical staff, the chief executive officer, and other senior hospital managers as having responsibility to take action when patient flow goals are not met. By January 1, 2014 hospitals must measure and set goals for curbing the boarding of patients in the emergency department. Such boarding times should not exceed 4 hours. Beyond that time, hospital leaders will need to explain to surveyors about the conditions that require boarding beyond the 4 hour mark.

DQE Can Help You Address Overcrowding

Addressing ED overcrowding is part of the spectrum of planning that DQE offers that includes medical surge and alternate care site initiatives. While overcrowding focuses on improving patient flow processes, medical surge planning centers around enhancing capacity and capability in order to maximize internal treatment space and resources. Such planning includes a rapid discharge protocol, creation of discharge areas, utilization of surgical and procedural recovery areas, cohorting of patients, and use of non-traditional treatment space. In addition, DQE’s medical surge planning also addresses degradation of services and Crisis Standards of Care. Alternate care site planning encompasses the delivery of care beyond the walls of the hospital.

DQE’s Medical Surge & Alternate Care Site planning process applies to all types of events such as the day-to-day acute, temporary demand for services as well as the response to emergent events such as mass casualty incidents, infectious disease outbreaks, or natural disasters resulting in injury/illness. It applies to all hospital staff in all organizational components and describes how the facility prepares for and manages the various key aspects of a medical surge operation.  Strategies outlined in this plan provide the hospital with options that promote institutional resiliency to respond to an event that results in a rapid patient influx or a sustained patient surge. For questions or assistance, give DQE a call at 800-355-4628.



  1. ACEP Task Force Report on Boarding. Emergency Department Crowding: High-Impact Solutions. April 2008.
  2.  ACEP News. Joint Commission takes on patient flow. Vol. 32; No. 2; February 2013.
  3. 2013 Hospital Accreditation Standards, The Joint Commission.

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