Executive Summary

While there is a plethora of proven strategies to address crowding, some of the most crowded EDs have failed to take full advantage of these tactics, according to a new study that examined the adoption of a range of both ED-based and hospital-wide interventions at hospitals between 2007 and 2010. The investigators are calling for a national strategy to address crowding as well as the implementation of new measures. They also say that more steps need to be taken so that hospital leaders are held accountable for ED crowding.

  • Researchers found that the average number of interventions adopted to reduce crowding increased during the study period from 5.2% to 6.6%, but that some of the most crowded facilities failed to adopt interventions that have been proven to work well.
  • For instance, 19% of the most crowded EDs did not use bedside registration and 94% did not adopt surgical schedule smoothing, an intervention that can be adopted at little or no cost.
  • Investigators note that the hospitals that have been successful at addressing ED crowding are those that embrace systemic solutions.

Focused effort boosts throughput, efficiency

During an 18-month period, 42 hospitals in 16 communities worked collaboratively to improve patient flow, and the results are encouraging. Investigators reported that two-thirds of the participating hospitals showed improvement on at least one of four measures:

  • discharged length-of-stay (LOS);
  • admitted LOS;
  • boarding time;
  • left without being seen (LWBS) rate.1

The hospitals were invited to participate through the Aligning Forces for Quality (AF4Q) program, an initiative of the Princeton, NJ-based Robert Wood Johnson Foundation. Each hospital identified one or more interventions that they intended to implement to improve patient flow, and then submitted data on the four measures. In addition, the hospitals regularly provided reports about any challenges they encountered and solutions to these challenges. Investigators reported that the 42 hospitals implemented a total of 172 interventions between October 2010 and March 2012. Among the two-thirds of participants that showed improvement, the average reduction in discharged LOS was 26 minutes, the average reduction in admitted LOS was 36.5 minutes, average reduction in boarding time was 20.9 minutes, and LWBS rates declined by 1.4 percentage points. While most participants demonstrated improvement during the collaborative, investigators reported that 14 hospitals did not make any progress on patient flow.

Jesse Pines, MD, MBA, a study co-author, observes that it is clear that to be successful in any type of quality improvement (QI), several ingredients are necessary. “You need a local leader who can be a champion. You need the support from management over time where it is really a priority and where whatever unit is trying to make a change gets the resources they need. You need the ability to look at data. You really need staying power over time so that [the QI effort] is not just a flash in the pan that is important for a couple of weeks and then goes away,” Pines says. “You really do need a sustained effort to keep things going. There is a tendency to slide back to the old way of doing things and you see this in many examples of quality improvement.”

Pines explains that, not unexpectedly, investigators traced improvement to these four key ingredients in the 42-hospital collaborative. “The hospitals that were not able to really have a champion, engaged leadership, and sustained power over time were not able to improve their ED flow in any real way and sustain it over time,” he says. However, Pines observes that collaborative efforts, through which participants regularly share solutions and ideas with each other, are very effective at keeping people engaged so that successful interventions can be sustained. “When there is peer-to-peer coaching, and you can hear the lessons from other people who are trying to do something similar … that can be very effective at [helping people] conceptualize how to do things locally,” he says.


  1. Zocchi MS, et al. Increasing throughput: Results from a 42-hospital collaborative to improve emergency department flow. Jt Comm J Qual Patient Saf 2015;41:532-553.