Emergency department overcrowding: causes and solutions

Abstract

Background 

Emergency department (ED) overcrowding is among the biggest and most important problems experienced by ED staff. The number of ED visits is on the increase and remains an unresolved problem. Emergency department overcrowding has become an important problem for emergency care services worldwide. There is a relationship between overcrowding and patients’ negative experiences of using ED and therefore reporting reduced patients’ satisfaction. This study aimed to identify the causes of ED overcrowding, determine the reasons for people’s use of EDs, and develop solutions for reducing ED overcrowding.

Methods 

This study used quantitative methods using a descriptive approach. The participants were patients who visited the ED. A questionnaire was administered to 296 participants between December 2021 and February 2022. The study included 5 different hospitals in Turkey. The data were analyzed using descriptive statistics.

Results 

This study identified the most common presenting medical problems in the ED and why patients used the ED. Reasons for using the ED included patients perceiving their condition as really urgent (62.8%), the ED being open for 24 hours (36.1%), and receiving faster care in the ED (31.4%). This study also developed recommendations for alleviating ED overcrowding.

Conclusion 

This study identified causes of ED overcrowding and some solutions for alleviating the issue. Emergency department overcrowding should be perceived as an international problem, and initiatives for solutions should be implemented quickly.

Introduction

Emergency departments (EDs) provide 24-hour uninterrupted services to any patient or injured person with a complaint and emergency cases.^[1,2] Providing this service to patients in need as soon as possible and prioritizing the most urgent patients are essential.^[2–4] However, patients presenting with nonurgent conditions to the ED causes overcrowding.^[2,5,6] Emergency department overcrowding is among the biggest and most important problems ED staff experience.^[3] The number of ED visits is on the increase and remains an unresolved problem.^[7] Emergency department overcrowding has become an important problem for emergency care services worldwide as ED visits gradually increase.^[8,9] Some studies have found a relationship between overcrowding and patients’ negative experiences in the ED that lead patients to report reduced satisfaction.^[10–12] Furthermore, high workloads and demand for care often cause ED staff to experience burnout syndrome.^[13]

There are many complex reasons that underlie ED use and ED overcrowding.^[5] For example, patients often prefer to use the ED instead of primary health care services for nonurgent conditions.^[7,14] Emergency department overcrowding also significantly affects the satisfaction of ED staff, which is an important concern for ED staff and managers.^[7,13,15] Using the ED for nonurgent conditions leads to ED overcrowding, thereby causing many problems related to ED services, staff, and users.^[5] Emergency department overcrowding results in long waiting times, delays in the treatment of patients who most require urgent care, decreased patient satisfaction, decreased quality of the health care provided, and increased health care costs.^{[2,3,12,16–18]}

Most previous studies on the reasons for ED use were conducted in high-income countries; thus, this multifaceted issue has not been sufficiently studied in the context of middle- and low-income countries.^[5] Identifying the causes of ED use in the context of middle-income countries is necessary because of differences in health care systems and cultural norms between high- and middle-income countries.^[5] In addition, statistical data obtained from the Ministry of Health in Turkey showed approximately 118 million in 2016, 124 million in 2017, 165 million in 2018, 178 million in 2019, 129 million in 2020, and 172 million in 2021 (Health Statistics from Ministry of Health, written communication, 2021), which is equivalent to approximately 1475, 1550, 2010, 2145, 1535, and 2050 ED visits per 1000 population, respectively. These statistical data showed that the number of ED visits per annum in Turkey is greater than the country’s total population. Therefore, an investigation into the causes of ED use is needed to provide solutions for alleviating ED overcrowding in Turkey.

This study aimed to identify the causes of ED overcrowding, determine the reasons for people’s use of EDs, and develop solutions for reducing ED overcrowding.

Methods

This study used quantitative methods by applying a descriptive approach.

Participants and settings

The participants of this study were patients who visited the ED. No specific inclusion or exclusion criteria were applied for participant selection. A questionnaire was developed and piloted by the researchers (Butun A, Kafdag EE, Gunduz H, Zincir V, Batibay M, Ciftci K, Demir D, Bayram R, Yigit E). The questionnaire was administered to 296 participants between December 20, 2021, and February 18, 2022. The questionnaires were filled out by the researchers (Kafdag EE, Gunduz H, Zincir V, Batibay M, Ciftci K, Demir D, Bayram R, Yigit E) who asked participants questions and received their answers face-to-face. This approach allowed us to obtain reliable data from the participants.

The settings for this study were as follows: Diyarbakir Training and Research Hospital (83 patients), Mardin Training and Research Hospital (59 patients), Kiziltepe Public Hospital (59 patients), Midyat Public Hospital (49 patients), and Ceylanpinar Public Hospital (46 patients). The total population of these 5 settings is currently approximately 2 million, and the hospitals in these settings have a bed capacity of 1750 in total. Thirty-two individuals refused to participate in this study. Table 1 shows the participant characteristics.

Table 1 - Sociodemographic Information of Patients Admitted to the ED

Variables	Number (n = 296)	Percentage, %
Age, y
18–30	151	51.0
31–40	76	25.7
41–50	38	12.8
51–60	17	5.8
≥61	14	4.7
Marital status
Married	188	63.5
Single	108	36.5
Occupation
Housewife	111	37.5
Teacher	16	5.4
Unemployed	16	5.4
Nurse	15	5.1
Doctor	4	1.4
Other	134	45.2
Educational level
Primary school	62	20.9
Secondary school	33	11.1
High school	72	24.3
Associate’s degree	19	6.4
Bachelor’s degree	61	20.6
MSc	10	3.4
PhD	2	0.7
Illiterate	37	12.6
Location of residence
Diyarbakir	83	27.8
Mardin	59	19.9
Kiziltepe	59	19.9
Midyat	49	16.9
Ceylanpinar	46	15.5

ED, emergency department; MSc, Master of Science; PhD, Doctor of Philosophy.

Data analysis

The data were analyzed using a descriptive analysis method.

Ethical considerations

Ethical approval was obtained from the Mardin Artuklu University Ethics Committee (date, December 14, 2021; reference, E-76272411-900-36850). In addition, the necessary permission was obtained from the Mardin Provincial Directorate of Health. Written informed consent was obtained from all participants.

Results

The participants’ most common medical complaints when visiting the ED were fatigue (26.7%), headache (23.3%), cough (22%), and other complaints (33.1%) (Table 2).

Table 2 - Most Common Presenting Medical Problems

Complaints	Number (n = 296)	Percentage, %
Fatigue	79	26.7
Headache	69	23.3
Cough	65	22.0
Vomiting	61	20.6
Sore throat	60	20.3
Abdominal pain	55	18.6
Shortness of breath	50	16.9
Fever	48	16.2
Dizziness	41	13.9
Chest pain	32	10.8
Diarrhea	27	9.1
Blackout	19	6.4
Other	98	33.1

Regarding their reasons for visiting the ED, participants stated that it was because they perceived that their condition was really urgent (62.8%), the ED is open for 24 hours (36.1%), and they receive faster care in the ED (31.4%). In addition, participants stated that they could not make timely appointments to visit outpatient clinics (30.7%), did not want to wait in the queue for outpatient clinics (24.7%), or the outpatient clinics were closed or had no doctor present (24%). Furthermore, patients could visit the ED without making an appointment (21.3%), could receive better care in the ED (15.5%), did not have another hospital or doctor to visit (14.5%), could receive laboratory results faster (11.8%), found staff in the ED to be more interested (10.1%), could access more resources in the ED (8.8%), found ED staff to be more skilled (8.8%), could receive better information about the disease and treatment process in the ED (7.8%), found the ED to be in close proximity with easy access (7.8%), and could receive free care in the ED (6.8%).

In addition, participants stated that they visited the ED based on the suggestions of the people around them—social network (6.1%), the ED was the only option for receiving their regular injections (4.7%), they were satisfied with previous positive experiences in the ED (4.4%), or they were directed to the ED by outpatient clinic doctors (4.4%) or their general practitioner (GP) (4.1%). In addition, some participants stated that their GP was inexperienced (3.4%), they were unable to trust their GP (3.4%), they had problems with the staff at a GP clinic (1.4%), and could solve all medical problems by visiting only one place (the ED) (1.4%). Table 3 shows the participants’ reasons for visiting the ED.

Table 3 - Reasons for Using the ED

Reasons for Using the ED	Number (n = 296)	Percentage, %
I came to the ED because my condition was really urgent	186	62.8
Emergency departments are open 24/7	107	36.1
I get faster service/care in the ED	93	31.4
Unable to get a timely appointment from an outpatient clinic	91	30.7
I do not want to wait in the queue at an outpatient clinic	73	24.7
Normal outpatient clinics are closed/no available doctors at this time	71	24.0
I can go to the ED without making an appointment	63	21.3
I get better service in the ED	46	15.5
There was no other hospital or doctor I could go to	43	14.5
Getting faster laboratory and radiology results	35	11.8
The staff in the ED are more interested	30	10.1
Availability of more resources such as medical devices, tests, radiology, and laboratory in the ED	26	8.8
Having more skilled staff in the ED	26	8.8
I get better information about my illness and treatment process in the ED	23	7.8
The ED is close to my home/workplace — I have easy access	23	7.8
I do not pay in the ED	20	6.8
I visited the ED with the suggestions of the people around me — social network	18	6.1
The ED was only option for receiving my regular injections	14	4.7
I was satisfied with my previous ED visit / I have positive past experiences	13	4.4
I was referred by the outpatient clinic doctor	13	4.4
I was referred by the GP	12	4.1
I think my GP is inexperienced	10	3.4
I do not trust my GP	10	3.4
All problems are solved quickly by a single doctor in the ED	10	3.4
I had problems with the staff at GP clinic	4	1.4

ED, emergency department; GP, General Practitioner.

The participant’s reported reasons for not using GPs included limited interventions in GP clinics (49.3%), limited resources (44.6%), limited working hours (35.7%), being unable to receive sufficient information about the disease and treatment process (20.4%), lack of interest (18.7%), transportation problems (15.3%), lack of experience with GPs (13.9%), dissatisfaction with GPs (9.5%), perception of patients regarding GP clinics where places providing vaccinations and infant and pregnancy follow-ups (9.2%), lack of trust in GPs (7.8%), and negative past experiences with GPs (7.1%). Of the participants, 16.3% visited the ED after seeing their GP. Such problems with GPs and GP clinics can lead patients to visit the ED rather than their GPs. Hence, improving GP clinics and eliminating problems with GPs could result in patients using those services rather than the ED, which could result in a reduced number of ED visits. Table 4 provides the participants’ reasons for not using GPs.

Table 4 - Participants’ Reasons for Not Visiting Their GP

Reasons for Not Visiting Their GP	Number (n = 296)	Percentage, %
Limited interventions are performed at GP clinics	145	49.3
Having limited resources	131	44.6
Having limited working hours	105	35.7
I do not get enough information from my GP about my disease and treatment process	60	20.4
I do not get enough interest from my GP	55	18.7
I went to the GP	48	16.3
Because of transportation difficulties	45	15.3
I think my GP is inexperienced	41	13.9
I am not satisfied with my GP	28	9.5
I perceive GP clinics as places where vaccination, baby, and pregnancy follow-up are performed.	27	9.2
I do not trust my GP	23	7.8
I had negative experiences in my previous visits	21	7.1
I had problems with the staff at the GP clinic	6	2.0

GP, General Practitioner.

Regarding solutions for reducing ED overcrowding, this study found that such solutions include increasing the number of qualified staff in the ED (74.3%), improving the appointment system for outpatient clinics (55.4%), making primary health care services more effective (46.3%), increasing the number of ED services and GP clinics (46.3%), and improving the physical, technological, and financial resources and capacity of EDs (37.5%). In addition, informing the community about how to use both EDs and GP clinics appropriately (35.9%), increasing health literacy (35.9%), and improving the working hours of GP clinics (24 hours for some of them) (34.5%) as well as increasing the public’s level of knowledge about EDs and encouraging them to use other health care services instead (30.5%) could also alleviate ED overcrowding. Developing the communication skills of ED staff (16.6%), establishing a telephone helpline patients can call to receive health information (16.2%), supporting ED staff financially and providing social space for them (13.8%), eliminating the negative impact of the media on EDs and ED staff (9.5%), improving coordination between health care services (8.8%), and providing effective and adequate security in EDs (8.1%) could also help to reduce ED attendance. Limitations of outpatient and GP clinics discourage patients from using these health care services and lead to ED use. Therefore, solving problems in outpatient and GP clinics could help reduce ED visits. Further recommendations for reducing ED visits are presented in Table 5.

Table 5 - Recommendations for Reducing ED Attendance

Recommendations for Reducing ED Attendance	Number (n = 296)	Percentage, %
Increasing the number of qualified staff in the ED	220	74.3
Improving appointment systems for outpatient clinics	164	55.4
Making primary health care services more effective	137	46.3
Increase the number of EDs and GP clinics	137	46.3
Increasing the physical, technological, financial resources, and capacity of EDs	111	37.5
Informing the community about how to use both EDs and GP clinics appropriately	106	35.9
Increasing health literacy	106	35.9
Improving working hours of GP clinics (working 24 h for some of them)	102	34.5
Encouraging the public to increase their level of knowledge about the ED and to use other health care services instead of EDs	90	30.5
Designing the EDs with an appropriate physical structure.	72	24.3
Improving the communication skills of ED staff	49	16.6
Establishing a telephone helpline where people can call and request information, help, and guidance about their health care needs	48	16.2
Creating sufficient social space for staff and providing financial support	41	13.8
Eliminating the negative impact of the media on EDs and their staff	28	9.5
Improving coordination between hospitals and other health care services	26	8.8
Arranging patient transfers and consultations in the hospital	24	8.1
Practicing adequate and effective safety procedures in the ED	24	8.1

ED, emergency department; GP, General Practitioner.

As Table 6 shows, 42.6% of the participants did not perform any procedures related to their health problems before going to the ED, 42.9% took medication to relieve their complaints before coming to the ED, 15.2% tried herbal remedies, and some tried techniques, such as hot-cold application, massage, and respiratory exercise.

Table 6 - Variables

Variables	Number (n = 296)	Percentage, %
Arrival to the ED
Private car	140	47.3
On foot	74	25.0
By public transportation	73	24.7
By ambulance	9	3.0
Did you take any action for your medical complaint before coming to the ED?
Taking medicine	127	42.9
No	126	42.6
Herbal treatment	45	15.2
Hot-cold application	29	9.8
Massaging	17	5.7
Respiratory exercises	10	3.4
Other	6	2.0
Have you visited the outpatient clinic or your GP about your medical problem before visiting the ED?
Yes	80	27.0
No	216	73.0
How many times have you been to the ED in the last year?
1	69	23.3
2	62	20.9
3	39	13.2
4	15	5.1
5	31	10.5
6–10	34	11.5
11+	46	15.5
Are you satisfied with the care you received in the ED?
Yes	178	60.1
No	50	16.9
Partly	68	23.0
Was the time allocated to you for treatment and care in the ED sufficient?
Yes	168	56.8
No	70	23.6
Partly	58	19.6
Has your medical problem get better after treatment and care you received?
Yes	131	44.2
No	44	14.9
Partly	121	40.9
Would you visit the ED for the same condition in the future?
Yes	194	65.6
No	56	18.9
Partly	46	15.5
If you have the same medical problem in the future, will you consider going to the GP?
Yes	98	33.1
No	142	48.0
Partly	56	18.9
Do you usually come to the ED with someone?
Yes	229	77.3
No	41	13.9
Sometimes	26	8.8
Are the number of staff in the ED sufficient?
Yes	109	36.8
No	151	51.0
Partly	36	12.2
Do you think the ED is overcrowded?
Yes	231	78.0
No	25	8.5
Partly	40	13.5

ED, emergency department; GP, General Practitioner.

Furthermore, 73% of the participants visited the ED directly, and 27% went to an outpatient clinic or GP before their ED visit. Regarding the number of ED visits in the past year, 23.3% of the participants had visited the ED only once, 20.9% visited twice, 13.2% visited 3 times, and 42.6% visited 4 or more times. Of the participants, 60.1% stated that they were satisfied with the care provided in the ED, 16.9% were unsatisfied, and 23.0% were partly satisfied. In addition, 56.8% of the participants stated that the time allocated to them for treatment and care in the ED was sufficient, 23.6% thought that the time allocated for them was not sufficient, and 19.6% were partly satisfied with the time allocated for their treatment and care.

Of the participants, 44.2% stated that their complaints were relieved after treatment and care they received in the ED, 40.9% stated that their complaints partly improved, and 14.9% stated that their complaints continued after receiving care in the ED. Furthermore, 65.6% of the participants stated that, if the same problems were to occur in the future, they would visit the ED again, 18.9% stated that they would not visit again, and 15.5% would possibly visit the ED again. In addition, 48% of the participants stated that, if their complaints returned in the future, they may not visit their GP, 33.1% stated that they would choose their GP, and 18.9% may choose to use their GP. Of the participants, 78% stated that the EDs were overcrowded and 8.5% stated that they were not. All the aforementioned variables are provided in Table 6.

Discussion

The ED is the first-place patients visit when they need urgent treatment.^[3] Based on statistics provided by the Ministry of Health in Turkey, EDs in Turkey appear to be unable to handle increases in the population and number of ED visits. Therefore, determining the reasons for ED overcrowding is crucial for alleviating this problem.

Overcrowding in EDs throughout the country has caused problems in patient care and health care services. In Turkey, a significant portion of the patients who visit EDs do not require urgent care, and overcrowding caused by those patients with nonurgent conditions lead to decreases in the quality of service provided to patients who require urgent care. This shows that the concept of urgency and how to use EDs appropriately has not adequately been explained to the general population. Regardless of the level of education, patients lack an adequate perception of urgency, and the awareness of society regarding using health care services appropriately is inadequate. This problem is growing for both health care providers and patients.^{[2,3,12,16–18]} In line with the results of this study, Chapman and Turnbull^[19] found that increasing awareness regarding available health services for their primary care needs is necessary. In addition, increasing awareness about how to use available health services appropriately and developing self-care abilities could contribute to improving individuals’ health care-seeking behaviors.

The results of questionnaires administered to the patients indicated that the EDs were frequently used because patients preferred EDs, thought that their health conditions were urgent, wanted to receive quick care, and the EDs are open 24 hours a day, 7 days a week. Other studies conducted in Turkey have reported that the quality of ED care and ability to receive quick care affect patients’ decisions to use the ED for nonurgent care, which leads to higher costs and increases the workload of ED staff.^[14,20] The results of this study also concur with those of Korczak et al.,^[21] who found that convenience of the ED and access to all tests and investigations in the ED contribute to ED attendance.

In line with existing studies, this study revealed that some of the reasons patients use EDs include that EDs need no appointments, an inability to receive an appointment from outpatient clinics, and an inability to find alternative services outside of working hours. The use of EDs for nonurgent conditions contributes to ED overcrowding. These findings are consistent with other existing studies.^{[3,7,18,20,22–25]} These results reflect those of Butun et al.,^[5] who also found that improving outpatient clinic services, including developing the communication skills of health care staff, raising standards of care, and improving patient flow, could contribute to patients’ positive experiences with such clinics, thereby increasing patients’ use of these clinics for their health care needs rather than the ED.

We also found that people prefer to use EDs over GP clinics because GPs have limited interventions and equipment available. In line with this study, Butun et al.^[5] and Malcolm et al.^[26] found that patients had insufficient knowledge about GP clinics and how to use them appropriately. Improving primary health care services such as improving the physical conditions of buildings, medical equipment, and qualified staff should be considered as solutions for reducing nonurgent ED visits and, therefore, improving the quality of care.^[1,27]

To the best of our knowledge, no other national-level studies on ED use have been conducted in Turkey. However, some studies were conducted by examining hospital records and obtaining information from patients, and inappropriate ED use was identified at different levels. This study is among those conducted in recent years to identify causes of the ED overcrowding, determine the reasons for nonurgent use of EDs, and develop solutions for reducing ED overcrowding in Turkey.

Conclusion

Although some studies have found overcrowding in and inappropriate use of EDs, research is limited on how to alleviate such problems. This should not be seen as a problem only for patients or staff. It also threatens all individuals by decreasing the quality of health care services, leading to dissatisfaction among patients and health care staff and increased health care costs. Emergency department overcrowding is a multifaceted issue that cannot be easily solved. Interventions need to be developed to reduce nonurgent ED visits, thereby promoting better continuity of care.^[28] Many agents need to be involved in solving this problem, including related governmental health care institutions, researchers, ED physicians, GPs, ED nurses, and patients. Emergency department overcrowding should be perceived as an international problem, and initiatives for solutions should be implemented quickly.

Nonurgent ED visits and long waiting times in the ED contribute to ED overcrowding and prevent patients with urgent needs from receiving timely treatment in EDs. Insufficient physical infrastructure, understaffing, and high staff workload contribute to ED overcrowding. This study found that the reasons for nonurgent ED use include having problems receiving an appointment from outpatient clinics, patients being directed to the ED by their own GPs, ease of transportation, and patients’ perception that they could be examined in the ED in a short time. Emergency department overcrowding could be reduced by increasing the number of qualified staff, raising patients’ awareness regarding appropriate ED use, improving the appointment system for outpatient clinics, making primary health care services more effective, and using GP clinics appropriately.