Hospital emergency departments get tips from AHRQ on how to reduce crowding and better triage patients

Research Activities, March 2012, No. 379

Crowding at emergency departments (EDs) in the United States, a problem for many years, has become a huge problem. The number of annual ED visits in the United States grew from 90.3 million in 1996 to 119.2 million in 2006, according to the Centers for Disease Control and Prevention. At the same time, the number of U.S. hospitals with operating EDs shrank from 4,019 in 1991 to 3,833 in 2006. Nearly half of EDs report operating at or above capacity, according to a new guide to reduce ED crowding from the Agency for Healthcare Research and Quality (AHRQ).

Further complicating matters, 9 of 10 hospitals report holding or "boarding" admitted patients in the ED while they wait for increasingly scarce inpatient beds. With long ED wait times, many patients end up frustrated, with about 2 percent leaving without being seen—a risky move for some.

"I think the hospital ED situation is chaotic right now," says Bruce Siegel, M.D., M.P.H., President and CEO of the National Association of Public Hospitals and Health Systems. "Hospitals know ED crowding is a problem, but they don't know the solution. There are a lot of ideas out there for how to reduce ED crowding—a little bit of snake oil sometimes—and AHRQ can play a huge role in getting the evidence base for strategies to improve ED flow and spread right practices."

AHRQ's new guide, Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals, helps hospitals plan and implement strategies to improve patient flow. In addition, an updated, newly released edition of AHRQ's Emergency Severity Index: A Triage Tool for Emergency Department Care, Version 4, Implementation Handbook, supports rapid and accurate triage of ED patients. This, in turn, helps reduce crowding. Hospitals know that ED crowding diminishes care quality, is costly, and compromises community trust. And soon, how they manage ED crowding will affect reimbursement for ED care. In 2013, hospitals will begin reporting ED crowding measures to the Centers for Medicare & Medicaid Services. These measures—for example, median time from ED arrival to ED departure, door-to-diagnostic evaluation by a qualified medical professional, and number of patients who leave before being seen—could affect hospital reimbursements for ED care.


Studies show that reducing ED crowding can improve care quality. An AHRQ-supported study reported in September's Research Activities found that children seen for acute asthma at a crowded ED (75th percentile of a crowding measure) were 52 to 74 percent less likely to receive timely care and 9 to 14 percent less likely to receive effective care than those at less crowded EDs (25th percentile of the crowding measure).

Guide to improving ED patient flow

Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals provides step-by-step instructions for planning and implementing strategies that can improve patient flow through EDs based on individual hospital situations. "For example, we encourage hospitals to identify the most likely causes of the gridlock they face and consider the human and financial resources available, then think realistically about the type of strategies they can afford to implement and maintain," says Megan McHugh, Ph.D., of Northwestern University, one of the AHRQ contractors that helped to develop the guide. The guide contains real-world examples of how hospitals have implemented these steps, the pitfalls they encountered, and strategies used to overcome them.

"Hospitals realize they don't have any more money to buy beds or build bigger emergency rooms, and they have to get better at patient flow," notes Dr. Siegel, who led an initial Urgent Matters Learning Collaborative from 2002 to 2008 sponsored by the Robert Wood Johnson Foundation (RWJF) to help hospitals identify and test patient flow strategies. Four of six hospitals that participated in a second RWJF-funded learning collaborative modestly reduced ED length of stay or the proportion of patients who left without being seen, according to a recent AHRQ-funded study.

The hospitals implemented one or more strategies—some of which grew out of the first collaborative. Led by Dr. McHugh and a team of researchers from the Health Research and Educational Trust, the study found that the improvement strategies hospitals chose and their impacts varied considerably. For example, one hospital reduced ED stays by 51 minutes by implementing front-end improvements (such as a more efficient intake process for nonurgent patients) and devoting additional staffing resources (such as more nurse practitioners and beds) for fast-track patients who are not very sick. Another hospital that implemented only front-end improvements had a 9-minute reduction in time spent in the ED. A third hospital reduced by 33 percent (from 0.6 percent to 0.4 percent) the patients who left without being seen by improving communication between the ED and inpatient units to facilitate hospital admissions. For example, they instituted a daily phone call with bed coordinators to discuss occupancy rates and transfer needs. A fourth hospital reduced ED stays by nearly 1 hour for mid-acuity patients by establishing a new expedited care process for them.

Dr. McHugh notes, "There may be many effective strategies for improving patient flow, but more research is needed to determine which strategies work best in different settings." AHRQ's guide is a first step in that direction.

Updated handbook for triaging patients

Improving triage is one strategy for enhancing overall ED flow. To help EDs improve triage of patients, AHRQ recently released a fourth version of its handbook on the Emergency Severity Index (ESI). The update includes a new pediatrics chapter and case studies that nurses can use to practice triage decisions with the ESI. The triage tool stratifies patients into five groups from 1 (most urgent) to 5 (least urgent) based on their severity of illness and need for resources such as tests or treatments. This approach accurately identifies patients who need to be seen immediately and those who can safely wait to be seen. Severity is determined by stability of vital functions and potential for life, limb, or organ threat.

A recent study by Dr. McHugh and colleagues (December 2011 Academic Emergency Medicine) based on a 2009 American Hospital Association survey found that 72 percent of hospital EDs are using the ESI triage tool and only 13 percent are using the 3-step triage tools, which were the dominant type of triage scale 30 years ago.

"I'm not surprised," says Kendall Hall, M.D., an emergency physician and medical officer in AHRQ's Center for Quality Improvement and Patient Safety. "The ESI is a validated tool and gaining momentum as a way to standardize the triage process in EDs. I think people see the value in it," she says. "What's great about the system is the high interrater reliability. With other systems, there can be a lot of variability in the triaging of patients across nurses. Just having a standardized way of triaging—where a patient with a certain presentation will be consistently triaged at a certain level—makes this system safer for the patients."

ESI level-1 patients, who require immediate life-saving care, comprise between 1 percent and 3 percent of all ED patients. A few examples of ESI level-1 patients are those with cardiac or respiratory arrest; an unresponsive, critically injured trauma patient; a flaccid baby; and a person in anaphylactic shock. ESI level-2 patients, who have a potential major life or organ threat, comprise 20 percent to 30 percent of ED patients. They are high-risk patients the triage nurse determines should not wait for care. Examples include patients with suspected heart attack, a suicidal or homicidal patient, and a hemodynamically stable woman who may have an ectopic pregnancy. Half or more of these patients are admitted to the hospital from the ED.

If patients don't fall into the first two categories, the triage nurse considers what resources, such as lab tests, the patient might need. Based on vital signs, history of present illness, nurses' clinical judgments, and factors such as medications, past medical history, and pain level, the triage nurse upgrades the patient to level 2 or assigns them to level 3, 4, or 5.

Historically, EDs used three-level triage systems (e.g., emergent/urgent/non-urgent), but research showed a lack of reliability and validity with these triage systems. Stratifying patients into five levels instead of three has helped considerably, says Debbie Travers, Ph.D., R.N., assistant professor of the University of North Carolina School of Nursing. She helped develop the ESI and worked with AHRQ to complete the latest update.

Dr. Travers explained to Research Activities that patients who have simple problems, such as needing a prescription to treat poison ivy, are level 5, and those who just need one straightforward intervention, for example, patients with an ankle sprain who need an x-ray, are a level 4. The complicated, but stable patients are rated level 3. An example is an elderly person with multiple medical problems who comes in with dizziness, which could be caused by many things. "This patient would require an involved workup to figure out what's causing the dizziness," says Dr. Travers. "These level-3 patients are going to be in the ED for a longer time."

New evidence from a study on pediatric triage by Dr. Travers and colleagues, supported by the Health Resources and Services Administration, formed the foundation for the new ESI pediatric chapter. That chapter details different triage levels based on, among other things, a child's temperature—whether there is a source for the fever, vaccination history, etc.

The pediatric information in the new ESI handbook was added at the request of practicing ED nurses. Says Dr. Travers, "In our study, we found that nurses at children's hospitals are most experienced with pediatric triage. But general hospital EDs that only see children occasionally don't see a high enough volume of pediatric cases to feel comfortable with pediatric triage. They love the new pediatric chapter, because there's a lot of information in there to help them."

The ESI may also help in addressing issues related to ED crowding, notes Dr. Travers. For example, the ESI provides standardized, reproducible information about patient acuity to assist with ED operations, such as the differing approaches to treating level 4 and 5 patients versus the level 1 to 3 patients. She points out that most EDs have some kind of fast-track area for less sick patients, so they don't have to wait a long time while the very sick patients are being seen. The 1 and 2 level patients are treated in the main ED and go into an ED bed the soonest.

"Getting the patient to the right place is one of the most important pieces of the emergency care puzzle," says AHRQ's Dr. Hall. "Before [ESI] there was a lot of variation in practice. Patients may have ended up in the wrong place or not getting the care they needed or getting it too late."

Page last reviewed March 2012
Internet Citation: Hospital emergency departments get tips from AHRQ on how to reduce crowding and better triage patients: Research Activities, March 2012, No. 379. March 2012. Agency for Healthcare Research and Quality, Rockville, MD.