The number of ED visits has grown by 25% in the past decade, but the number of hospital EDs and inpatient beds has declined during that same time-frame, resulting in crowded conditions nationwide. Nearly half of EDs are operating at or above capacity, and few consistently achieve recommended wait times for all ED patients. The impact of ED crowding has been profound, leading to poor quality care, increased mortality rates, and lower patient and staff satisfaction.

Major Findings on Improving Patient Flow

In an effort to strengthen the evidence base for patient flow improvement strategies, Megan C. McHugh, PhD, and colleagues evaluated the efforts of five hospitals that participated in a collaborative aimed at improving patient flow and reducing ED crowding. Results were published in the September 13, 2011 Journal for Healthcare Quality. Participating hospitals implemented seven improvement strategies over 18 months as part of the collaborative. By the end of the study, four of the five hospitals had at least one fully implemented improvement strategy and had experienced modest improvements in patient flow, including reduced length of stay and fewer patients left without being seen.

The improvement strategies and their impact varied considerably in the study, according to Dr. McHugh. “Several factors appeared to influence the impact of strategies, including ability to overcome implementation challenges, the timing of implementation, and the type of strategy selected. We also found that the staff time and expenses involved in the adoption of the ED strategies were highly variable.”

Few studies have considered time and expenses associated with implementing patient flow strategies. In Dr. McHugh’s study, time spent planning and implementing the strategies ranged from 40 to 1,017 hours per strategy. The most time-consuming strategies were those that involved extensive staff training, large implementation teams, or complex process changes. Many respondents in the study reported that more time should have been allocated for staff training. Only three of the nine strategies assessed in the study involved sizable expenditures, ranging from $32,850 to $490,000. “Hospital and department leaders should set realistic expectations for the staff time and resources needed to support planning and implementation,” says Dr. McHugh. “They should also recognize that a variety of staff members will likely need to be involved.”

Help From AHRQ on ED Crowding

The AHRQ has published a guide based upon the results of the study by Dr. McHugh and colleagues. The guide provides hospitals with a step-by-step process for developing and adopting patient flow improvement strategies. After forming a multidisciplinary patient flow improvement team and collecting performance data, a critical step in reducing ED crowding is to select a patient flow improvement strategy (Table 1). “These strategies can potentially reduce ED crowding,” Dr. McHugh says. “Several patient flow improvement strategies adopted by hospitals in our analysis are described in the AHRQ guide. They include mid-track, which expedites care for mid-acuity patients; immediate bedding, in which patients are immediately placed in beds for registration and triage rather than made to wait in waiting rooms; and protocols for specialty consultations so that the process of requesting and completing specialty consults in the ED is expedited.”

The Robert Wood Johnson Foundation, the American College of Emergency Physicians, the Institute for Healthcare Improvement, and other quality improvement organizations also offer guidance and toolkits for hospitals. Strategies to facilitate change and overcome implementation challenges, such as those reported in Dr. McHugh’s study, are also provided in the AHRQ guide (Table 2). “Developing a strategy to address common barriers may leave leaders better prepared to implement the improvements,” states Dr. McHugh.

The Future for ED Crowding and Medicare Payments

Considering the detrimental impact that ED crowding can have on the provision of care quality, national policy-level interventions are needed. CMS recently announced the inclusion of five ED crowding-related measures under the Hospital Inpatient Quality Reporting Program initiative. In the future, hospitals will be required to report on the following measures to CMS in order to receive full Medicare payment updates:

1)  Median time from ED arrival to ED departure for discharged patients.
2)  Door-to-diagnostic evaluations by qualified medical professionals.
3)  Patients left before being seen.
4)  Median time from ED arrival to ED departure for admitted patients.
5)  Median time from admit decision time to time of departure for admitted patients.

Dr. McHugh says that enticing hospitals to pay more attention to crowding and patient flow is important. “Public reporting of patient flow measures, including the measures in pay-for-performance programs, will provide hospitals with an incentive to address patient flow and ED crowding in an effort to decrease these burdens in the future.”


McHugh M, Van Dyke KJ, Howell E, et al. Changes in patient flow among five hospitals participating in a learning collaborative. J Healthc Qual. 2011 Sep 13 [Epub ahead of print]. Available at:

McHugh M, Van Dyke K, McClelland M, Moss D. Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals. (Prepared by the Health Research & Educational Trust, an affiliate of the American Hospital Association, under contract 290-200-600022, Task Order No. 6). AHRQ Publication No. 11(12)-0094. Rockville, MD: Agency for Healthcare Research and Quality; October 2011.Available at:

Van Dyke KJ, McHugh M, Yonek J, Moss D. Facilitators and barriers to the implementation of patient flow improvement strategies. Qual Manag Health Care. 2011;20:223-233.

McHugh M, Van Dyke KJ, Yonek J, Moss D. Time and expenses associated with the implementation of strategies to reduce emergency department crowding. J Emerg Nurs. 2011 Sep 8 [Epub ahead of print].

McHugh M. Four reasons to confront crowding in the emergency department. Trustee. 2010;63:33-34.

Robert Wood Johnson Foundation: Urgent Matters Program Toolkit. 2006. Available at: