Combatting the Crowd

Authors: Peter Fielding / Editor: Nikki Abela / Reviewer: Charlotte Davies / Codes:  / Published: 09/11/2021 / Reviewed: 11/03/2025

Crowding kills. Overcrowded EDs are less safe for the patients they care for. For every 72 patients waiting in your department for longer than eight hours, one will die.

It happens for a number of reasons, and RCEM has long tried to push for solutions, some of which are here. This blog is an updated and amalgamation of several old RCEMLearning blogs – one of which focussed on paediatric crowding.

Overcrowding occurs when the hospital at large, is unable to meet the demands for care placed upon it by the patients. As a result, the Emergency Department (ED), which is generally regarded as the “front door” of the hospital, is unable to cope with the number of patients the hospital is caring for.

It happens for many reasons: staff, space, internal hold ups and exit block. In short, if all roads lead to the same place, the place gets more busy and things can slow up. Add to this the problem of being unable to move patients out and EDs become heavily crowded: much like many in the country are as I type this now.

Community factors often cited by patients include (rightly or wrongly!) inability to access primary care appointments, poor social networks and having nobody to support a parental or guardian decision that their child is OK and does not need medical support, and pressure on community healthcare services (such as OPAT services for home intravenous antibiotics), which may otherwise facilitate discharge from ED and enable care in the community. Other issues, mainly in adult hospitals, include exit block from the hospital at large, e.g. for patients waiting for community placements.

Problems can occur with input, output and throughput.

In the ED, staffing, the skill mix of the staff on shift, a lack of adequate physical space in which to see patients, and over-zealous use of patient investigations.

In the wider hospital, problems with IT systems, waits for imaging and other investigations, availability of inpatient beds or opinions from specialist teams also contribute to delays, and therefore, exit block.

Exit block, which happens when patients in the ED requiring admission to the hospital are unable to be moved to a bed on a ward because of a lack of availability, is also a large contributor.

These lists are not exhaustive, but serve to highlight the point that ED overcrowding cannot be solved within ED alone. It is a much bigger problem than that.

This blog will serve to explore what we can do, within ED, to help ensure good patient flow, reduce overcrowding and improve patient experience. The evidence is clear. ED overcrowding is associated with poorer outcomes across a wide range of ED performance parameters. Overcrowding is associated with poorer patient care, with a rise in mortality and morbidity with increasing 6-hour and 12-hour patient waits.

The key to ensuring good patient flow from an ED perspective is to reduce the amount of time each patient spends in ED. This is correlated with increased patient satisfaction, reduces morbidity and mortality in adult practice, and helps prevent overcrowding.

What tools or strategies are available to us in ED?

1. Triage

The first interaction a patient has with the clinical team in the ED is triage. Triage is a process designed to quickly assess a patient in terms of the nature of their presenting complaint, and the acuity of their presentation. This process helps to allocate finite ED resources (personnel, cubicle or room, monitoring) to those who need it most. It is a system which helps alert the clinical team to those most unwell, and who need timely clinical intervention. 

Ideally, all patients are seen and triaged within 15 minutes of booking in as the highest risk to the ED is the “untriaged” and not-known-about patient in the waiting room. This 15 minute target, aimed at reducing that risk, needs to be balanced with the concept of getting it right from the very first step of the patient journey, to make the system more efficient.

We should look to use triage to our advantage. Triage is a time to initiate basic steps to reduce the time each patient spends in ED overall. It is the time to administer antipyretics, analgesia to those with injuries, commence trials of fluid in those likely to benefit, and to collect specimens which take time to collect, such as urine samples. Play specialist staff should be made aware of anxious or distressed children, to help prepare them to be seen by the medical team. Signposting parents and carers at this stage as to what their visit to ED is likely to entail can help to manage expectations, and also ensure that patients are set up to have all of the information and specimens likely to be required to aid diagnosis and management once they are seen by a member of the medical team.

Providing the triage practitioner is suitably trained, studies have shown that initiation of basic investigations during triage can help to speed up the time to critical decision making in each patients care. Issues surrounding privacy can prevent collection of urine samples in the ED waiting room, and this is a time-consuming task which can extend a patients stay in the ED and block a clinical cubicle in the department. Allocation of a more private space for this purpose, even within the main waiting room, would be of benefit.

Triage is traditionally performed by nursing staff. In paediatric practice, with emphasis put on minimising both over-investigation and also invasive tests for children, it is difficult to order and perform blood tests from triage. This process can be assisted by having a physician as the triage practitioner, or as part of the triage team. This has been shown to lead to faster diagnosis, shorter wait times and improved patient flow through ED.[3] It also allows those children who require blood tests to be identified early, so that these investigations can be performed in a timely manner, with quicker access to results to inform subsequent management.

Triage also allows the process of streaming to occur. Streaming is a process by which those patients arriving through the front door in ED are cohorted into groups, often based upon the nature of their presenting complaint. It may be, for example, that minor injuries, those with coughs and colds, or babies with feeding problems are grouped together, and a dedicated number of clinicians are allocated to that particular group. This allows a focused approach on a particular clinical problem, and can enable those suitable for a quick discharge are identified, seen promptly and managed accordingly. It is useful to use streaming for patients of low acuity, who from triage are identified as being likely able to be discharged home, to ensure that they do not have prolonged waits in the department while children with increased acuity move ahead of them in the queue as a clinical priority. A senior, experienced clinician can help to alleviate overcrowding by managing such patients quickly and efficiently. There is evidence to suggest that streaming helps promote patient flow and reduce waiting times in ED compared to a comparative system not using a streamed model.[8] Some departments are also trialling streaming to other places directly from triage, e.g. to health visitors, clinics, urgent care centres and pharmacists. This may make triage longer, but reduces the waiting time and improves departmental efficiency further along the patient journey, for those who do need to be seen in the ED.

In some EDs, a senior clinician or nurse in triage has aided the diverting of patients to more appropriate services, such as clinic slots, walk-in centre appointments, pharmacists or specialty teams.

2. Rapid Assessment and Treatment (RAT assessment)

RAT assessments involve a senior member of the medical team, often a consultant, providing a time-limited medical assessment of each child arriving at the ED. This allows minor, self-limiting conditions to be identified early and to be discharged with appropriate advice, re-direction of suitable presentations to more appropriate services, and appropriate investigations and management to be initiated for patients as soon as they arrive at the ED. Those patients who are likely to require admission or more time-consuming investigation would otherwise be triaged and wait to be seen in the more conventional manner. 

This process is a very useful way of identifying and managing quick wins. It is a powerful tool in preventing overcrowding, and ensures patients attending ED are approaching the correct service. It has been shown to reduce time to be seen by a doctor, and overall wait time in ED.

This needs to be balanced by the requirement for the consultant to be elsewhere, and requires an appropriate private space to be available for such use. 

3. “Doc-in-a-box” or See and treat

This process allocates a particular team to an ED cubicle. Such a team may consist of a doctor or nurse practitioner, a healthcare assistant and a nurse. A suitable patient stream is then identified by the ED team leader, and a separate queue created for this mini-MDT. The team involved should have the skillset to quickly manage a wide range of complaints, such as minor injuries and fractures. The team being based in one geographical location in ED helps to prevent time being wasted searching for a suitable cubicle to see patients, and also helps to mitigate against patient flow problems that happen when all available areas to see patients in ED become occupied.

4. Patients seen in primary care

A lot of patients arrive at the ED having been seen before-hand by their general practitioner or at a walk-in centre. Patients who have already been seen by a qualified health professional should ideally be referred to a relevant inpatient team, e.g. direct to surgical team, providing they do not need resuscitation or immediate stabilisation.

5. Innovative Measures
Examples of other solutions include reverse queuing, boarding, virtual clinics, same day emergency care (SDEC) and 111 first.

6. Knowledge Dissemination

Of course, its all well and good to come up with pathways for care, but if the patients or the staff do not know about them, then they will still present to the ED for treatment there, without streamlining. Therefore it is important to teach and update our staff and our patients that there are different ways to access care and the ED may not necessarily be the best place for it.

This can be done for example, through public health messages on social media platforms, working with inpatient teams to create appropriate information leaflets with directions on how to access their help, even outside of normal working hours.

Keeping staff up to date is another issue altogether and the information overload that accompanied COVID definitely had a negative effect on wellbeing and engagement.

With crowded classrooms a thing of the past, we now need to look towards virtual ways of learning and communication. At RCEMLearning, this is not something new to us – when the covid pandemic first started, we created a regularly updated COVID tab, an induction module which was used during the national changeover day in August (if your hospital hasnt signed up, they can do so here), as well as advising on virtual education methodology, and even planning some teaching for you! 

These are some of the techniques that are employed locally in our busy tertiary-level paediatric ED. We hope this article shares some of the techniques that we are mostly all using, and encourages others to come forward with their ideas or experiences of systems that you use in your workplace to help manage crowding in ED. Please tweet or comment to share your ideas on how to prevent problems going into winter.

7. Be Kind

Civility saves lives, we know this. We must be kind to ourselves, our colleagues, our patients, and their relatives. Strive to promote wellness. If you dont know where to start, try here and here.

For staff and yourself, be mindful that a one size fits all approach does not work. What could be fixed with a yoga session for one person, may need a debrief and vigorous run for another.

Andy Tagg said it best here: