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Am J Emerg Med. 2006 Nov;24(7):787-94.

The effect of crowding on access and quality in an academic ED.

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Department of Medicine, The University of Chicago, Chicago, IL 60637, USA.



Emergency department crowding has the potential to cause undesirable outcomes. We evaluated ED access and provider and patient assessments of quality.


This multimethod study, done in an urban academic ED, included descriptive analysis of administrative records, paired physician and nurse provider surveys, and pre- or postpatient surveys regarding expectations and experiences. Our outcomes were rates and characteristics of patients who left without being seen (LWBS), provider ratings of crowding/compromised care, and patient satisfaction.


During data collection periods, 11743 patients registered, and 9% LWBS. Patients who LWBS tended to be younger than 45 years (relative risk [RR] = 1.7; 95% confidence interval [CI], 1.5-1.9), of nonurgent/stable triage acuity (RR = 3.1; 95% CI, 2.5-3.8), and without insurance (RR = 1.5; 95% CI, 1.3-1.7). Seventy-four percent of all patients had insurance, and 28% were private. Doctors and nurses had 81% agreement (kappa = 0.54) in their assessment of crowded conditions, which were temporally associated with LWBS rates (P < .01). In 47% of 57 shifts, at least 1 provider felt that crowding was compromising quality of care. Of 423 sequential ED waiting room patients approached, 310 (73%) enrolled and 174 (56%) of these completed phone follow-up. On average, patients felt that they should be seen within 1 hour but expected to wait for 2.1 hours. Patient's perceived that wait times on follow-up averaged 3.5 hours, 5+ hours for LWBS patients. Visit satisfaction was inversely related to patient's perceived wait times.


We find that ED crowding increased LWBS rates and patient satisfaction. Systemwide changes in ED organization will be necessary for the ED to fulfill its role as a safety net provider and meet public health needs during disaster surge capacity.

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