Clinical update

How to manage crowding in the emergency department

New guidance looks at the emergency care pathway and offers advice on how to tackle crowding

Royal College of Emergency Medicine guidance looks at the emergency care pathway and offers advice on how to tackle crowding

Picture: iStock

Essential information

Crowding is when the number of patients occupying the emergency department (ED) is beyond the capacity for which it was designed and resourced to manage at any one time, says the Royal College of Emergency Medicine (RCEM).

It is the most important problem facing EDs worldwide and is on the rise again in the UK, according to the college. Crowding potentially threatens the safety of patients, who may have increased mortality and poorer experiences of care; staff, who may experience burnout and more illness; and organisations, whose performance and reputation may be jeopardised.

Visible effects include ambulances queuing outside EDs,

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Royal College of Emergency Medicine guidance looks at the emergency care pathway and offers advice on how to tackle crowding

Picture shows the entrance to an emergency department. New guidance looks at the emergency care pathway and offers advice on how to tackle crowding
Picture: iStock

Essential information

Crowding is when the number of patients occupying the emergency department (ED) is beyond the capacity for which it was designed and resourced to manage at any one time, says the Royal College of Emergency Medicine (RCEM).

It is the most important problem facing EDs worldwide and is on the rise again in the UK, according to the college. Crowding potentially threatens the safety of patients, who may have increased mortality and poorer experiences of care; staff, who may experience burnout and more illness; and organisations, whose performance and reputation may be jeopardised.

Visible effects include ambulances queuing outside EDs, trolleys in corridors and long waits for patients, both to be assessed and transferred to a ward.

What’s new?

In September, the RCEM published What to do if Your ED is Becoming Crowded Again After the Initial COVID Period.

In this new guidance the college states that ‘crowding kills’ and can only be tackled through clear and consistent system leadership, backed by action. ‘ED crowding was not acceptable before COVID and it is even more dangerous in the presence of COVID.’

It adds that EDs cannot be expected to cope without being part of a wider organisation and system response, and ‘shouldn’t be seen as having “elastic walls”’.

The RCEM highlights five reasons why EDs become crowded:

  1. Too many patients to manage with the available staff.
  2. Too many patients to be managed within the available space.
  3. Internal hold-ups, such as waiting for imaging or specialist opinions, disagreements with teams about accepting patients, or overly complex systems.
  4. There is exit block or slow flow.
  5. A combination of all of the above.

‘Exit block will trump everything,’ the guidance states. Most commonly, this happens when patients are unable to be moved to a bed on a ward because of lack of capacity.

Key issues

The RCEM guidance is based around three key questions:

  1. Has your ED adopted relevant good practice?
  2. Is your organisation doing all it can to reduce crowding?
  3. What should local emergency medicine leaders do if they feel their organisations are not responding effectively?

On good practice, it suggests asking whether ED internal processes are as efficient, effective and consistent as they should be. In situations where the ED footprint has been altered to cope with COVID, have staffing requirements been suitably changed? Can critically ill patients with infectious disease be treated safely in the ED?

How you can help your patients

All healthcare professionals, including nurses, have a duty to report patient safety concerns. This may include speaking to your professional lead in the organisation or potentially your professional regulator – the Nursing and Midwifery Council – if you feel your anxieties are not being properly addressed. Local escalation routes should be fully exhausted first, advises the RCEM. Consider flagging concerns as a team, as it may mean issues can be raised impersonally and with more authority.

Expert comment

Justin Walford, senior practice development nurse in the emergency department at the Royal Sussex County Hospital, Brighton

Justin Walford is senior practice development nurse in the emergency department at the Royal Sussex County Hospital, Brighton

‘Among what’s good about the Royal College of Emergency Medicine guidance is it looks at all aspects of the emergency care pathway, including flow throughout the department, documenting many of the hold-ups along the way.

‘As an emergency nurse, it doesn’t give me the authority to go to managers and tell them exactly what is needed, so we can make changes on a shift-by-shift basis. But, as it’s aimed at those who are planning care, it does facilitate managers to create pathways and try and tackle some of the system blockages.

‘The situation in emergency departments has returned to almost the same as pre-COVID days. We’re getting more patients waiting for treatment in corridors and bed blockages are back. During COVID, a lot of attention has been rightly paid to infection control in lots of areas, but trying to get help specifically for corridors has been more difficult.’

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