The document discusses emergency department overcrowding as a global issue requiring local solutions. It provides definitions of overcrowding and describes its worldwide prevalence, indicators, and impacts. Overcrowding leads to adverse patient outcomes like increased mortality, as well as negative impacts on healthcare systems, staff, and quality of care. The document analyzes the input, throughput, and output factors that contribute to overcrowding. These include an increasing complex patient population, limited primary care access, organizational challenges, and issues with admissions, bed management, and discharge processes. Data on bed waiting times from a major Malaysian hospital demonstrate the severity of access block problems. Overall, the document frames overcrowding as a complex problem requiring coordinated, multi-faceted

1. Emergency Department
Overcrowding
“Global Crises Mandating Local Solutions”
Datuk Dr Mahathar Abd Wahab
Consultant Emergency Physician
Hospital Kuala Lumpur
27 January 2023

2. OVERCROWDING
• Various definition
• The need for emergency healthcare services exceeds the available
resources to provide emergency care to patients within an appropriate
time frame [1]
• Imbalance (disequilibrium) in service provision
• True “overcrowding”
• Depends on the locality or institution
• Different causative factors

3. OVERCROWDING WORLDWIDE
• 1987- first statewide conference on ED “overcrowding” in NY, USA
• Nov 2022- IFEM Global campaign against ED over-crowding
• The current state of over-crowding experienced at hospital Emergency
Departments in many nations globally is an unacceptable and
preventable threat to patient safety which must be immediately
addressed
• Dec 2022- NHS UK on the edge of collapse

4. ED
OVERCROWDING WORLDWIDE

5. Despite being a global issue,
overcrowding MUST NOT be
accepted as normal
ED Overcrowding is a tip of iceberg phenomenon

6. ED Overcrowding Indicators
1. Patient LOS
2. Call Not Around (CNA)
3. Ambulance Diversion
4. Boarding Time
5. % Resources Utilisation

7. ED Indicators – EMTS

8. IMPACT ON SYSTEM
Adverse Outcomes
• Increases triage time
• Increases waiting times for treatment [2]
• Increases length of stay in ED
• Ambulance diversion
• Delayed care for time-critical illnesses i.e., acute myocardial infarction,
acute stroke, severe sepsis

9. IMPACT ON SYSTEM
Adverse Outcomes
• Decreases quality of care [1]
• Increases medication error, delay and omission [3],[12]
• Time to thrombolysis, analgesia and antibiotics
• Decreases infection prevention and control
• Increases morbidity and mortality
• Increased risk of death by 34% at 10 days for patients who
experienced ED overcrowding during hospitalization [4]

10. 0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
BWT <2H BWT > 12H
Mortality Rate (%)
BWT <2H BWT > 12H
The mortality rate was 2.5% for those boarded for less than 2 hours and
increased to 4.5% for those boarding for greater than 12 hours [2]

11. IMPACT ON PATIENT
• Decreases patient satisfaction [1]
• Lack of privacy and preservation of dignity [5]
• Increases patients leaving without being seen (LWBS) [11]
• Increases discharge against medical advice (DAMA)
• Patients discharged home despite high-risk clinical features

12. IMPACT ON STRUCTURE AND
EQUIPMENT
• Waiting halls and corridors being transformed into makeshift clinical area
• Overutilisation of medical equipment
• Ventilators, monitors, infusion pumps, ultrasound machines
• Increases rate of equipment breakdown
• Fastens wear and tear
• Overutilisation of point of care tests (POCT) and consumables
• Increases operational cost [1]

13. IMPACT ON ORGANISATION
• Workforce ‘mismatch’
• Causes staff burnout due to high workload
• Staff leaving ED→ vicious cycle
• Increases patients/ relative violence towards staff due to frustration
• Affects the quality of learning for young doctors
• EM less attractive from career point of view
• Changing role of emergency physicians
• From resuscitation and stabilisation, to diagnostic, definitive, and de-
escalation therapy

14. CAUSATIVE FACTORS
OF OVERCROWDING

15. True problem:
Looking at ED
overcrowding in
isolation

16. INPUT THROUGHPUT OUTPUT
Treat & Observation
Discharge
Treat & Admit
Diagnostic, Therapeutic
Resuscitation
Ambulance
Referral
Walk-in
EMERGENCY MEDICINE AND TRAUMA SERVICE

17. 17
Primary
triage
Consultation
AMBULANCE
DROP
ZONE
&
PATIENT
ARRIVAL
Secondary
triage
1 2 3
Disposition
Re-Consultation
CLINICAL CARE
Referral
Laboratory
Radiology
Procedure
Red
Yellow
Emergent
4
Care
Areas
See &
Treat
Discharge
Admit
5 Inpatient
Bed
Outpatient
Registration
- SPP
Payment
Admission
Registration
- SPPD
Yellow
Urgent
CCaRS
POBs
Green
Non
Emergency
Arrival to consult (ATC) KPI : > 70% within 1.5H
Bed waiting
time (BWT) < 4H
Length of stay (LOS) KPI : > 70% within 2H
I
ii
iii
4 Call
Not Around <5%
iv
RECEIVING CARE
Sub-processes:
Turn around times
DISPOSITION
Sub-processes
times:
Pharmacy
Specialist Clinic
Appt
KK Appt

18. Arrival Triage Treatment Referral Disposition Admission
Leave to
ward
Register
Int
Ext
Walk-in
Referred
Limited apt
Primary
Secondary
Critical patients
Resuscitation
Stabilisation
Diagnostic
ECG
POCT
Imaging
Lab
Pharmacy
Multi-departments
Subspecialties
Multi-tiers
Procedures
Intervention
Imaging
Lab
Pharmacy
Admit
Observe
Discharge
Mortuary
Optimisation
Monitoring
De-escalation
ECG
POCT
Imaging
Lab
Pharmacy
Triage time Waiting time Bed waiting time
Length of stay 1: non-admitted patient
Decision making
Treatment time
Ceiling therapy
Length of stay 2: admitted patient
Push System
Pull System
Emergency
Timeline of Emergency Department Work Processes

19. INPUT FACTORS

20. PATIENT
• Patient’s complexity
• Increasing geriatric, obese, socially displaced
population
• Increasing prevalence of NCD→ multiple co-morbidity
• Hence - ‘processing time’ longer
• Surge of seasonal illnesses
• Eg. dengue, COVID-19 and influenza
• Patients bypassing appointment-based clinic for walk-in
treatment
• Unnecessary ambulance activation by stable patients
• ‘RM 1 service’
• Lower income groups crowded government hospitals

21. LIMITED ACCESS
TO PRIMARY CARE
• Limited service hour
• Limited imaging and POCT service
• Limited options of treatment – skeletal service
• Appointment-based treatment

22. Emergency and Trauma Department
HKL
• Average attendance: 350-600 patients/day
• Non-critical patients: 70%
• Semi-critical patients: 15-20%
• Critical patients: 10-15%
70
20
10
Non-critical Semicritical Critical

23. PATIENT ATTENDANCE TO ETD HKL IN YEAR 2022
ACCORDING TO ZONE
7290
6518 6742
6174
6957
8010 8108 7654
7003 7121 6922 7014
1434
1219
1385
1384
1655
1701 1805
1726
1751 1995 2009 2123
1729
1883
2120
1465
1723
1910
2309
2060
1904
2099 2240 2254
0
2000
4000
6000
8000
10000
12000
14000
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Non-Critical Semi-Critical Non-Critical

24. PATIENT ATTENDANCE TO NON-CRITICAL ZONE
DURING AND AFTER OFFICE HOUR
4996
4488
3929
4090
4890
5076
5466
5076
4581
4739 4760 4749
2294
2030
2813
2084 2067
2934
2544 2578
2422 2382
2162 2265
0
1000
2000
3000
4000
5000
6000
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
After OH/ PH 8AM-5PM
Extended Hour
clinic started

25. NON-EMERGENT REFERRAL
• EXTERNAL
• KK to ED i.e. HPT urgency,
hyperglycemia, minor injury /
trauma, stable angina
• KK to specialist clinic via ED
• Interhospital referral (stable) via
ED
• INTERNAL
• Specialist clinics to ED
• Specialist clinic to other specialty
via ED
• Specialist clinic for ward admission
via ED

26. THROUGHPUT
FACTORS

27. ORGANISATION & HR
• Inadequate number of staff - staff mismatch (ED & Beyond ED)
• Inexperienced staff
• High turnover staff – MOs, PPP, JT
PATIENT
• Complex cases require multiple diagnostic tests and intervention
• Complex syndrome – multiple referrals ( > 1 specialties / subspecialties)

28. SYSTEM
• Referral
• Delayed referral by ED doctors
• Delayed review by primary team
• Over-investigation
• Delayed decision making by the primary team
• Inexperienced/ lack of communication with senior doctors
• Multiple referrals to attend
• Multi-tiers system
• 1st (MO) , 2nd (Registrar), 3rd (Specialist), 4th (Consultant)
• Patient requires assessment outside of ED

29. SYSTEM
• Manual system
• Portal System - Lab samples, blood products and imaging films
• Registration
• Medical records / filing

30. STRUCTURE AND
EQUIPMENT
• Bottleneck points
• ECG test
• X-rays
• Biochemical Tests (POCTs /
labs)
• Facility outside of ED
• X-rays and CT scan
• Endoscopy
• Angio suite (IR)
• OT
• Ambulances
• Intra-hospital transfer

31. OUTPUT FACTORS

32. SYSTEM
• Admission System (Processes)
• ‘PUSH’ system: admission decided by ED Team
• Unclear criteria
• Inappropriate admission
• ‘PULL’ system: admission decided by primary team
• Delayed decision of admission
• Inexperienced doctor
• Multiple levels (HO/MO/Reg/Specialist)
• Lack of communication with seniors/ specialists
• Unnecessary investigation (& repeated investigations) with long
turnaround time

33. SYSTEM
• Bed Management
• Disintegrated bed management system 9silos & manual)
• Maldistribution of beds between departments
• Mismatch between high acuity beds availability and demand
• Discharge Decision and Discharge Processes
• Late discharge
• Low discharge rate over the weekend due to skeletal staffing
• Beds occupied by discharged patients (delay pick up by family) and homeless
ones
• Step-down care & Follow Up Care
• Lack of post-acute care facilities
• Limited Fast Track Follow up Clinic

34. ACCESS BLOCK & BOARDING
• Access block
• The situation where patients are unable to gain access to appropriate
hospital beds within a reasonable amount of time, no greater than 8 h
[6]
• Boarding (Pending Cases)
• The practice of holding patients in the ED after they have been
admitted to the hospital because no inpatient beds are available [7]
• Unsafe ‘corridor medicine’
• Dissipation of resources
• 40% of staff time spent to attend inpatient boarding rather than new
patients [8]

35. ETD HKL 2022 BED WAITING TIME

36. 1689
1346
1501 1554
1908
1498
2378
2751 2723
2905 2894
3059
2396
0
500
1000
1500
2000
2500
3000
3500
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan
JAN 2022 - JAN 2023
NUMBERS OF PATIENTS ADMITTED IN 2022- 2023
Jan-June: involved medical beds only
July- 23 Jan: involved medical, neuromed, nephro, ortho, surgical, neurosurgical, uro and onco beds

37. 54
48 48
52
62
50
77
89 91
94
96 99
104
0
20
40
60
80
100
120
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan
JAN 2022 - JAN 2023
AVERAGE NUMBERS OF PATIENTS ADMITTED PER
DAY
Jan-June: involved medical beds only
July- 23 Jan: involved medical, neuromed, nephro, ortho, surgical, neurosurgical, uro and onco beds

38. 67.7
76.4
72.4
89.2
76.5 77.9
57.4 57.2
64.9 63.6 62.4
58.9
64.4
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan
JAN 2022 – JAN 2023
PERCENTAGE OF PATIENTS ADMITTED LESS THAN 8
HOURS
1143 1028 1087 1386 1460 1167 1364 1573 1767 1848 1805 1543
Jan-June: involved medical beds only
July- 23 Jan: involved medical, neuromed, nephro, ortho, surgical, neurosurgical, uro and onco beds
1802

39. 79.2
85.6 84.6
94.9
87.3
89.5
69.8 69.3
75.8 75.8 75.4
70.7
76.6
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan
JAN 2022 – JAN 2023
PERCENTAGE OF PATIENTS ADMITTED LESS THAN 12
HOURS
1337 1152 1270 1475 1666 1340 1659 1907 2063 2201 2182 1835
Jan-June: involved medical beds only
July- 23 Jan: involved medical, neuromed, nephro, ortho, surgical, neurosurgical, uro and onco beds
2162

40. 94.7
96.9 97.3
99.5
97.9 98.3
88.6 88.7
92.3
91.4
92.2
88.4
92.5
80.0
82.0
84.0
86.0
88.0
90.0
92.0
94.0
96.0
98.0
100.0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan
JAN 2022 – JAN 2023
PERCENTAGE OF PATIENTS ADMITTED LESS THAN 24
HOURS
1599 1304 1460 1547 1868 1472 2107 2439 2512 2655 2668 2704
Jan-June: involved medical beds only
July- 23 Jan: involved medical, neuromed, nephro, ortho, surgical, neurosurgical, uro and onco beds
2216

41. 90
42 41
7
40
26
271
312
211
250
226
355
176
0
50
100
150
200
250
300
350
400
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan
JAN 2022 – JAN 2023
NUMBER OF PATIENTS ADMITTED AFTER 24 HOURS
Jan-June: involved medical beds only
July- 23 Jan: involved medical, neuromed, nephro, ortho, surgical, neurosurgical, uro and onco beds

42. 3
2
1
0
1 1
9
10
7
8 8
11
8
0
2
4
6
8
10
12
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan
JAN 2022 – JAN 2023
AVERAGE NUMBERS OF PATIENTS ADMITTED
AFTER 24 HOURS PER DAY
Jan-June: involved medical beds only
July- 23 Jan: involved medical, neuromed, nephro, ortho, surgical, neurosurgical, uro and onco beds

43. 4.8 4.1 4.4 2.8 4.2 4.1 6.6 6.3 5.1 5.4 5.5 6.1 5.2
67.4
52.9
60.4
50.9
69.6
50.3
75.1
82.8
113.5 113.3
143.3
78.2
126.9
0.0
20.0
40.0
60.0
80.0
100.0
120.0
140.0
160.0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan
JAN 2022 – JAN 2023
MEDIAN AND MAXIMUM BED WAITING TIME (IN HOUR)
Jan-June: involved medical beds only
July- 23 Jan: involved medical, neuromed, nephro, ortho, surgical, neurosurgical, uro and onco beds

44. EMTS MALAYSIA
• 5.9 million patients in 2018
• 350,000 critically ill patients
• 112,000 stayed in ED > 4
hours
• 10,500 stayed in ED > 24
hours

45. SOLUTIONS;
OVERRIDING PRINCIPLES - THEMES
1. Two tier strategies (governance)
I. National Levels
II. LOCAL Solutions
2. Intra department patient management system
3. Inter department patient management system
4. Digitalization of medical services
5. Public - private partnership
6. Community participation & empowerment
7. Human resource development & sustainability
8. Structural capacity improvement
9. Financial support & sustainability

46. SOLUTIONS - OPTIONS
• Immediate:
• Factors within ED governance
• Intermediate:
• Involving integration / collaboration between departments (hospital
governance)
• ICT Development
• Long term:
• Requiring additional fund,
• Policy Changes
• Structural development

47. IMMEDIATE
(< 6 months)

48. ORGANISATION
1. Proactive specialist supervision
▪ Specialist cover during ‘peaks’
▪ Timely decision making
▪ Minimizes errors
▪ Prevent over-investigation
2. Training
▪ Regular training for all categories
▪ Competency training - creating ‘TL’
▪ Intensified training
▪ seasonal illnesses occur (Dengue / Covid / Influenza etc)

49. SYSTEM
1. Pre-hospital care
• MECC triage system (no to ambulance transportation & hospital care)
• Onsite ‘Treat and Release’ guided by online medical direction / off line
protocols
• Sending ‘right patients back to their follow up centres’ – need top down
because involving University Hospitals
2. ED triage
1. Patient Redirection (Triage Away)
▪ Patient Redirection based on objective criteria and access to other
healthcare facilities
▪ HTAR 2022 - 210 cases (no adverse events)
2. Implementation of EMTS Revised Triage Category 2019 from 3 tiers to 5 tiers
triage system
3. See and Treat by specialist or senior doctor

50. SYSTEM
3. Fast-track pathways for time sensitive & high-risk clinical conditions –
simultaneous activation, specific clinical criteria
1. STEMI-HISNET network
2. Acute stroke protocol
3. Testicular torsion pathway
4. Acute Limb Ischaemia
5. Polytrauma
6. Mental Illness

51. Malaysian Triage Scale (Revised 2022)

52. SYSTEM
4. Accessible and Just-in-Time (JIT) clinical protocol [5]
▪ Eg. Low risk chest pain, acute renal calculi, COVID-19 management,
Dengue
5. Imaging pathways - HIT protocols, Trauma Series etc
6. End-of-life (EOL) care / palliative care / ‘ceiling of care’ provision
▪ As per patient’s wish or specialist assessment
▪ Development EOL care for EMTS including at PHC level
7. Protocol-driven short-stay unit / multidisciplinary short stay unit
▪ 23 to 38% shorter LOS, 17-44% lower subsequent admission [9]
8. ED bed management team
▪ Decreases admission time by 100 mins [2]

53. SYSTEM
9. Referral
▪ Feedback to KK on appropriateness of referrals
▪ Audit on primary team referral response time
▪ Clinical governance groups with primary ED stakeholders
10.Discharge
▪ Structured home care [10]
▪ EMWATCH: virtual home-based follow-up via video call
▪ EMACC: physical follow-up clinic shortly after being discharged
▪ Automation of KK follow-up using apps
▪ List of specialty service surrounding for DAMA patients
▪ Fast access to specialty clinic

54. SYSTEM
11.Regular audit on the clinical system
▪ Miss fracture
12.Data Monitoring – Daily ED overcrowding report to the Crisis
Preparedness and Response Centre (CPRC)
▪ LOS of non-admitted patients
▪ Percentage of admission within 8, 12 and 24 hours (BWT)
▪ Average (median) bed waiting time
▪ Percentage of patients requiring high O2 concentration

55. STRUCTURE & EQUIPMENT
1. Increase consumables and POCT allocation
▪ Lab TAT
▪ Comprehensive POCT (Labs / ECGs / Dstix)
▪ Imaging TAT
▪ POC Imaging (X Rays / USGs)
2. Hospital Admission & Discharge lounges
▪ Increasing number of ‘beds’ in ED is NOT the solution

56. HUMAN RESOURCE
1. Correct the maldistribution
▪ Re-distribution of human resources based on services need
2. Lengthening the turnaround time for junior staffs
▪ (approximately 60% MOs in Major ED have experience less
than 2 years)

57. INTERMEDIATE
(6/12 to 24/12)

58. ORGANISATION
1. Leadership buy-in from top to bottom
▪ Acknowledge the issues
▪ Provide forthcoming solution
2. Integrated hospital bed management unit
▪ Governance & authority to Hospital BMU
▪ Leveling of all beds: no beds belong to specific department
▪ Information on hospital bed's utilisation and availability
▪ Real-time beds status, LOS etc.
3. Patient Flow Team [11]
▪ Multidisciplinary teams with different knowledge which can offer different
perspective of problems and potential solutions

59. SYSTEM
1. Patient Registration and Patient Tracking system
1. Adopt & expand the existing system
▪ EDRICS (HTAA / HKL)
▪ Bedwatchers (HTAR)
2. ‘Referral’ Unit
▪ Avoiding cumulative delay
3. Ward discharge system
▪ Preemptive discharge advices (based on predicted LOS)
▪ Predischarge checklist
▪ Daily discharge before 12 p.m.
▪ Enhance weekend discharge
▪ Provision of discharge lounge
4. Step-down care: collaboration with out-hospital-structures
1. Hospis
2. Nursing homes – public, private, NGOs
3. Rehabilitation centres

60. SYSTEM
5. Primary care services
▪ Extended hours
▪ Limited walk-in clinic for patients without appointments
▪ Family medicine specialist (FMS) empowerment for direct admission
▪ ‘Intrahospital facility run by primacy care providers after office hours
and weekends
6. Establishment of direct admission pathways from KK and specialist
clinics
▪ Adherence to MOH Guideline for interfacility transfer of stable patients
from referring hospital direct to the ward
7. Study on elective cases schedules and its impact on ED overcrowding and
high-acuity beds availability
8. Seamless Lean Initiatives ( ETD – Medical – Others)

61. STRUCTURE & EQUIPMENT
1. Increase consumables and POCT allocation
▪ Lab TAT
▪ Comprehensive POCT (Labs / ECGs / Dstix)
▪ Portal Services to Pneumatic tube system
▪ Imaging TAT
▪ POC Imaging (X Rays / USGs)
2. Hospital Admission & Discharge lounges
▪ Increasing number of ‘beds’ in ED is NOT the solution

62. LONG TERM
(> 2 years)

63. ORGANISATION
1. Increase the number of staffing (& sustainability plan)
2. Orientation program for all new staff
3. Health administrator, private sectors and politicians buy-in
4. Education program for public – ‘Changing Medical Health Seeking
Behaviour’
▪ The role of emergency department
▪ NCD and its complications (Hospital admission for NCDs as an adverse
events)
5. Homeless patients
1. Foreign embassies responsibility to facilitate their citizens’ admission and
discharge
2. Active involvement of NGO to facilitate homeless patients’ disposition
6. Development of URGENT CARE Centres

64. SYSTEM
1. Digitalization of health care system
▪ Patient tracking: bed watcher system
▪ Asset tracking and monitoring
▪ Bedside registration
▪ Integrated bed management unit (BMU)
▪ Total hospital information system (THIS): e-MR, labs, imaging,
pharmacy
2. Patient empowerment: creation of self-triaging apps guiding patients to
▪ Remain at home and monitor symptoms
▪ Seek treatment in primary care centres
▪ Seek treatment in emergency departments
▪ Activate ambulance call

65. STRUCTURE AND EQUIPMENT
1. ED structure
▪ Imaging facilities within ED
▪ Trauma resuscitation bay with lead-lining protection
▪ Prevent patients from being transferred out from ED for imaging
2. Installment of pneumatic tube system
3. Abolition / reduce of non-emergency area
▪ Expand more spaces for semi-critical and critical patients

66. STRUCTURE AND EQUIPMENT
1. Upgrading KK facilities to cater non-emergency and non-
critical patients
▪ Imaging, POCT service
2. Investment on home care and community service
▪ Ensure geriatric patients with complex health problems
receive expert care within the community

67. FINANCE
1. Revision of national health insurance scheme for lower
income category
▪ A system allowing people to go to either government or
private facilities with a universal payment scheme

68. CONCLUSION
1. ED overcrowding is an indicator of the health system inefficiency
1. Targets – Achieving Equilibrium
2. Significant impact to patients’ outcome, health care system and
organization
3. Global issue which mandating local solution
4. Intervention from;
1. various stakeholders,
2. society,
3. health administrators and government with strong political will
5. Immediate, Medium & Long Term

69. REFERENCES
1. Rasouli HR et al. Outcome of Overcrowding in Emergency Department, A Systematic
Review. Arch Acad Emerg Med. 2019; 7(1): e52
2. Salway RJ et al. Emergency Department Overcrowding: Evidence-Based Answers to
Frequently Asked Questions. REV. MED. CLIN. CONDES - 2017; 28(2) 213-219
3. Kellerman AL. Waiting Room Medicine: Has It Really Come To This? Annals of
Emergency Medicine Volume 56, No.5 : November 2010
4. A Guttmann, Schull MJ, Vermeulen MJ. Association Between Waiting Times And Short-
term Mortality And Hospital Admission After Departure From Emergency Department:
Population-based Cohort Study From Ontario, Canada. BMJ 2011, 342, d2983
5. Savioli G et al. Emergency Department Overcrowding: Understanding the Factors to
Find Corresponding Solutions. J. Pers. Med. 2022, 12, 279
6. Forero R, McCarthy S, Hillman K. Access block and emergency department
overcrowding. Crit. Care 2011, 15, 216

70. REFERENCES
7. Crowding Position Statement. American College of Emergency Physicians. April 2019
8. ED Overcrowding Position Statement. Australasian College for Emergency Medicine
March 2021
9. Ross MA et al. Protocol-driven emergency department observation units offer savings,
shorter stays, and reduced admissions. Health Aff (Millwood). 2013 Dec;32(12):2149-56
10. Shepperd S et al. Hospital at home' services to avoid admission to hospital. Cochrane
Database Syst. Rev. 2016, 9, CD007491
11. Section 1. The Need to Address Emergency Department Crowding. Content last
reviewed July 2018. Agency for Healthcare Research and Quality, Rockville, MD.
12. Fee C, Weber EJ, Maak CA, Bacchetti P. Effect of emergency department crowding on
time to antibiotics in patients admitted with community-acquired pneumonia. Ann Emerg
Med 2007; 50(5):501-509.e1.