Perspectives and Experiences Regarding the Impacts of Emergency Department Overcrowding: A Rapid Qualitative Review

Key Messages

• This review used a rapid best-fit framework analysis approach to synthesize 9 included studies exploring how people who engage with emergency department (ED) services experience and understand the impacts of ED overcrowding, access block, and boarding on quality of care, patient safety, and the well-being of health care professional learners and staff working in the ED. None of the included studies were conducted in Canada.
• The included studies detailed how people who engage with ED services understand the ED as a location that is appropriate for providing short-term treatment to people requiring critical or emergent care, but inappropriate for providing care to patients for extended lengths of time. Study participants described experiencing ED overcrowding, boarding, and access block as transforming the ED into an unsafe environment where the risk of avoidable patient harm increased due to the accelerated depletion of available equipment, space, and human resources. They observed that this unsafe environment led to patients experiencing delayed, missed, and inappropriate care, resulting in potential or actual physical harm, threats to their human rights and dignity, exposures to secondary suffering, reduced satisfaction, and worsening emotional and psychological states.
• Participants reported that ED overcrowding, access block, and boarding had, for the most part, negative impacts on health care professional learners and staff working in the ED. Some ED staff reported that these phenomena led them to experience increased exposure to violence and physical harm, emotional and moral distress, dimensions of burnout, and/or missed learning opportunities for health care professional learners. Some ED staff reported experiences of camaraderie and collaboration necessarily forged as a coping mechanism to manage adversity in the context of overcrowding. Amid the challenges experienced within their practice setting, some experienced staff also perceived overcrowding as providing opportunities to exercise and expand their existing knowledge and skills.
• Considering these findings, decision-makers seeking to address the adverse impacts of ED overcrowding, access block, and boarding on quality of care and patient safety may explore facilitating the integration of routine preventive care into ED processes; enhancing communication within the ED; optimizing available equipment and space; giving patients information before and during their stay to manage their expectations; and enhancing staff’s access to education and resources necessary to better address the needs of patients who frequently experience extended stays in the ED and require specialized care beyond that which ED staff typically have the training and experience to provide. They may prioritize interventions that alleviate, rather than add to, the workload of ED staff. Additionally, they may assess and explore working conditions in the ED with a lens of promoting the well-being and retention of ED staff. By drawing on the findings of this review, they may, for example, consider exploring how to incentivize senior staff to remain in their positions, enhance learning opportunities for health care professional learners, and promote interprofessional collaboration. They may also consider investigating and addressing systemic factors contributing to overcrowding, access block, and the recruiting and retaining of health care providers in their jurisdictions.
• Decision-makers may also further explore how proposed interventions might address or exacerbate ethical and equity issues raised by ED overcrowding, including: the fair and equitable allocation of scarce resources; harms and forgone benefits to patients, health care providers, and other hospital staff; and inequitable access to and experience of ED care by patients, including impacts on patients’ dignity, relationships with care providers, and trust in EDs or health care systems. They may consider providing targeted support to groups identified as disproportionately at risk of harm in overcrowded EDs, including but not limited to: those requiring extended lengths of stay, those with limited agency to self-advocate or gain appropriate attention and care, those who are unable to perform activities of daily living, or those experiencing mental health emergencies. They also may consider that the included studies provided limited or no insight into the perspectives of people belonging to equity-deserving groups with a history of harm and lack of agency in the ED, including but not limited to: Indigenous people, Black people, and other people of colour; people with disabilities; people experiencing houselessness; those experiencing language barriers without access to a professional interpreter; and members of the 2SLGBTQ+ community. More research is needed to understand how these and other equity-deserving groups experience overcrowding, access block, and boarding as impacting their quality of care and safety.