International Solutions to Emergency Department Overcrowding
As countries around the world struggle with overcrowding in their emergency departments, some are trying solutions that could help ease volume pressures and even point the way to new answers for EDs in the United States. Of 41 member countries of the International Federation of Emergency Medicine (IFEM) surveyed in November 2022, 100% reported overcrowding in their EDs. The problem, IFEM insisted, is preventable,1 although real solutions may lie outside the ED itself.
The United Kingdom’s National Health Service (NHS), approaching its 77th anniversary, has its pluses and minuses, said Adrian Boyle, MD, an emergency physician at Cambridge University Hospitals and president of the UK’s Royal College of Emergency Medicine. “One of the minuses is we have almost the least number of hospital beds” per capita of comparable countries in the Organization for Economic Cooperation and Development.
That under-bedding, estimated as a shortfall of 20,000 hospital beds, exacerbates the overcrowding for patients stuck in the ED. “We reckon that 15% of hospital beds are taken up with people who are waiting for some sort of discharge,” Boyle said.
More than two decades ago, the NHS introduced a standard for 95% of accident and emergency (A&E) patients to be either admitted, transferred, or discharged from the ED within four hours of arrival. “That was successful, but at a financial cost,” he said.
Some patients were pushed into “off the clock” observation areas and others were admitted to hospital beds unnecessarily to get them off the ED’s books. “We’re now in a situation where the government recognizes it can’t afford to achieve the four-hour standard,” Boyle said.
In recent years, the NHS has experimented with several approaches designed to ease A&E pressures, including educating the public about when to call for an ambulance versus seeking alternate care. NHS 1-1-1 is a call center where patients can get advice on where to take their health problems.
In some settings, primary care services with general practitioners on site have been located adjacent to emergency departments. Same day emergency care clinics can accept patients who were first seen in the ED and then sent over for consultations with specialists. Other drop-in resources with various names include walk-in urgent treatment centers for minor injuries and illnesses. One approach posts a senior doctor at the front door of the emergency department to immediately assess patients upon arrival, allowing for faster triage and improved patient flow.
“My colleagues and I spend time doing what’s called ‘call before convey,’ where an EMS technician in the field can speak directly to a medical consultant to ask, ‘I’m not sure this person needs to go to the hospital; is it okay, can I just discuss it with you?’” Boyle said. That involves quite a lot of pathway navigation.
NHS is very data-driven systemwide, he added. “We also keep pushing system-wide accountability,” given that the UK is not likely to build a lot more hospital beds, lacking both economic and political capital for that at this time. Real solutions will require being data-driven and being honest about what the data tell us.
Community Emergency Medicine
Community emergency medicine is an approach for taking emergency department services to the patient at home or on the street using alternative care pathways, said Tony Joy, MD, an emergency medicine physician at the Royal London Hospital who also works as medical director for the Essex & Herts Air Ambulance Trust.
Joy said his dedication to the concept, which he has spent the past decade developing, stems from a belief that the interface between the hospital, the ambulance service, and the community needs to be strengthened. “Emergency departments are not islands in the health care system but very much need to be part of an integrated care structure,” he said.
The busier the emergency department, he said, the more likely it is to not deliver the right care. Pressures can lead through rapid triage to mechanisms that encourage the ordering of tests that perhaps aren’t clinically indicated, overmedicalizing the care. Because the overcrowding and stress also make it a tougher environment to work in, with higher states of burnout and job frustrations, it’s getting harder to recruit doctors for the ED and paramedics for prehospital care.
One model developed in London is called the physician response unit (PRU), designed for doctors to deliver the care of the ED in the patient’s home. “We’re trying to empower clinicians with a slightly different blend to their job plans, where they spend some time in the ED and time outside working alongside the ambulance service,” Joy said.
The physician in the PRU is paired with an ambulance service EMT. They go out to patients’ homes or workplaces or wherever the emergency is. Seventy-five percent to 80% of those patients don’t get conveyed to hospitals. In London, this approach uses a fleet of rapid response vehicles stacked with a range of advanced equipment, instead of full-sized ambulances.
An associated service called Remote Emergency Access Coordination Hub (REACH), established during the COVID-19 pandemic, puts an emergency medicine senior clinician on the phone to talk to the ambulance crews and offer them options other than conveying the patient to the hospital.
“Another option might be to say we need to see this person in the hospital, but we don’t need to see them right now,” Joy said. “We can give them an appointment to come in tomorrow.”
Joy said REACH saved 17,000 ambulance visits to north east London hospitals between 2021 and 2024, out of 24,000 emergency calls fielded. Bringing forward a senior clinical decisionmaker earlier in the patient’s journey can help to reduce the need to push the patient to the A&E or hospital.
“We’ve tried to create a number of new care pathways, for instance with frailty, for older patients with a bunch of complex medical problems—the kind of complexity where you really benefit from putting a doctor into the patient’s home,” Joy said. “They can prescribe, do point-of-care blood analysis, perform ultrasound. We can run a number of different definitive tests and make an informed clinical assessment for many patients that had they have been taken to the hospital, might have been admitted for often-lengthy spells on a ward.”
“During COVID, we focused on clinically vulnerable patients, like those with cancer who were receiving chemotherapy where if they got unwell, actually the hospital became a dangerous place, a new hazard to be avoided. So, we offered to take emergency care into the community for those patients,” Joy said, thereby relieving some pressures on the ED.
“And it has some important soft influence as well, which is that it shows that things can be done differently,” he said. “It illustrates that there is an alternative model of care that isn’t dependent on the hospital but is dependent on community integrated care structures and that sort of thing.” This model has gained quite a lot of traction, with services being set up around the UK following this model of care.
Other Countries’ Solutions
Eric Revue, MD, head of the Emergency Department and Pre-Hospital Service at Lariboisiere Hospital in Paris, France, who also chairs the Pre-Hospital Section of the European Society for Emergency Medicine, said ED overcrowding is a complex, difficult problem across Europe. “We call it an overcrowding problem, but it’s much more than that,” he said. “And solutions are difficult to find.”
These solutions should focus on pre-hospital care optimization, streamlining of ED workflow, and expanding hospital capacity. Although many patients often come to EDs for nonurgent reasons. “The main problem is we don’t have enough beds. And we are concerned for the wave of elderly patients still to come,” Revue said.
In France, a mobile intensive care unit staffed with critical care doctors and nurses can go to the patients, particularly in emergencies when transporting them to the ICU is not feasible. There is a national emergency triage and dispatch system called SAMU (Urgent Medical Aid Service). “But do we need to update our triage system?” Revue said. “We also dream of other solutions, including better partnerships between emergency services and hospitals.”
Other European countries are also experimenting with related solutions, including specialized ED units, overflow units, and off-hours general practitioners. Denmark has tried to educate the public about preventive health and how not to use the emergency department for nonemergent situations. Belgium has paramedic intervention teams to handle noncritical cases. And Netherlands has general practitioner clinics co-located alongside emergency departments.
Australia has struggled with ED overcrowding, adopting programs such as short stay units, optimized bed management, improved patient flow through rapid triage, waiting room nurses to reassess and monitor those waiting to be seen, emergency medicine leaders getting involved in promoting wellness, and other enhanced community-based care options.2
A growing trend of virtual ED services makes consultants available to identify patients better directed to urgent care clinics outside of the hospital. A recent study of an Australian program to encourage discharge by paramedics at the scene of emergency ambulance calls found that subsequent hospital admissions and adverse events were rare, suggesting generally safe decision-making by the paramedic at the front lines.3
Boyle thinks the UK’s emergency care system is evolving toward greater integration and blurring of the boundaries between the hospital and out-of-hospital care settings. Joy said medical consultant-led emergency care ought to start in the pre-hospital environment, not just in the hospital. “We need a more patient-centered, slightly de-medicalized, more holistic approach,” said Joy.
In some contexts in different countries, recognition is growing that EMS—and the paramedic’s role—haven’t received the full measure of respect they deserve. Paramedics in new and expanded roles may be an important part of future solutions to the world’s ED overcrowding problem.
References
- Global Campaign Against ED Overcrowding. International Federation for Emergency Medicine. https://www.ifem.cc/global_campaign_against_ed_over_crowding.
- Crawford K, Morphet J, Jones T, et al. Initiatives to reduce overcrowding and access block in Australian emergency departments: A literature review. Collegian. 2014 Dec.; 21(4): 359-366.
- Villani M, Nehme E, Cox S, et al. Outcomes of adult patients discharged at scene by emergency medical services. BMJ Emergency Medicine Journal. 2024 Jul 22; 41(8):459-467. doi: 10.1136/emermed-2023-213777.
