Emergency department crowding

This thesis focuses on emergency department (ED) crowding. In the first part (ED crowding in the Netherlands) the current state of EDs regarding patients’ length of stay and ED managers’ experiences of crowding are described.
Part two (input factors) contains three studies which describe the case load of an inner-city ED. Self-referrals, ED return visits, and frequent ED visitors are described. The results suggest that it is possible to reduce the input of patients: a part of the self-referrals are suitable for primary care and many unscheduled return visits may be prevented. Efforts to improve ED flow focusing on frequent visitors will have minimal impact on ED crowding.
The three studies in part three (throughput factors) show that a stream system attached to the triage system is useful to objectively identify patients suitable for treatment by emergency nurse practitioners (ENPs). ENPs showed high diagnostic accuracy. The ENP model of care is an important strategy in improving the throughput of ED patients.
In part four (output factors), a study on walkouts is presented. Furthermore, the effects of flexible bed management are assessed. Access to hospital beds is essential in reducing ED crowding.
This thesis shows that ED crowding exists in the Netherlands. Since patients are harmed in crowded EDs, crowding should be considered as unacceptable. Therefore, a consistent collection of standardised ED data is needed to accurately measure and monitor ED use and ED flow nationwide and to measure and evaluate the effect of interventions to improve patient flow.