This article is the third in a three-part series which seeks to dissect the challenge of emergency department (ED) crowding; why it occurs, why it’s a problem and what we need to do to overcome it. The creation of this series is driven by the ever-pressing need to secure the sustainability of our EDs, which move closer and closer to breaking point with each day. This series has been curated with the support of senior Emergency Medicine Consultants from NHS England.

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In the previous two articles we’ve defined the problem and outlined its impact on patient outcomes and quality of care delivery. But now, the question remains; how can we tackle this global problem once and for all?

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Tools which provide superficial measurements of ED crowding to aid decision making, such as the NEDOCS Score for Emergency Department Overcrowding and the International Crowding Measure in Emergency Departments (ICMED), are available to emergency medicine leaders, but their limitations and shortcomings are widely recognised.

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As such, other solutions have been tried and proposed with varying degrees of efficacy. These include; increased access to primary care and general practitioners (GPs), alternative models of care, and patient flow modelling via computer simulation.

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Let’s evaluate each solution before outlining where we must apply our efforts next if we are to truly alleviate ED crowding.

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Increased Access to Primary Care and General Practitioners

Increasing access to primary care, as well as the appropriate redirection of low-acuity patients, have both been considered to reduce crowding [1]. One UK study found a reduction in low-acuity presentations as a result of implementing GP-led walk-in centres [2]. Additionally, various studies have shown that increasing GP opening hours has had positive effects on ED crowding [3-6], although the efficacy varies across the studies.

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Alternative Models of Care

Alternative models of care, such as the Discharge to Medical Home model, have also aimed to reduce the number of low-acuity patients entering the ED. These models route low-acuity and ambulatory ED patients to a primary care clinic, providing a connection to primary care for the patient. During clinic hours, walk-in patients to EDs can be assessed, and if deemed low risk, can be scheduled a same-day primary care appointment [7].

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However, it is worth noting the position of the Royal College of Emergency Medicine, who have consistently argued that the proportion of low-acuity patients who could be treated in alternative healthcare settings is no more than 15%, so this suggests that the effect of this solution could be limited. [8].

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Patient Flow Modelling Via Computer Simulation

Computer simulations that involve patient flow modelling allow ED leaders to test the impact of changes to care delivery more efficiently, in real time, before implementing them. 

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This may not only have a positive impact on causes related to input, but also throughput and, most importantly, output [9]. Interventions for crowding need to involve more than just the ED [10], so strategies that target input and throughput have had only some positive effects, and these effects are likely to be limited and unsustainable. By predicting demand for hospital care via computer simulation, ED leaders can see when exit block is likely to occur, and therefore respond with more appropriate interventions to address output also [11].