This paper summarises the consequences of emergency department crowding. It provides a comparison of the scales used to measure emergency department crowding. We discuss the multiple causes of crowding and present an up-to-date literature review of the interventions that reduce the adverse consequences of crowding. We consider interventions at the level of an individual hospital and a policy level.

The extent of ED crowding in the UK is unknown. The problem is probably mitigated by process standards such as the 4 h standard. The causes and effects of crowding are likely to be the same as overseas, but there is little research to validate this. The best solutions are not known.

Objective To determine whether full elbow extension as assessed by the elbow extension test can be used in routine clinical practice to rule out bony injury in patients presenting with elbow injury. Design Adults: multicentre prospective interventional validation study in secondary care. Children: multicentre prospective observational study in secondary care. Setting Five emergency departments in southwest England. Participants 2127 adults and children presenting to the emergency department with acute elbow injury. Intervention Elbow extension test during routine care by clinical staff to determine the need for radiography in adults and to guide follow-up in children. Main outcome measures Presence of elbow fracture on radiograph, or recovery with no indication for further review at 7-10 days. Results Of 1740 eligible participants, 602 patients were able to fully extend their elbow; 17 of these patients had a fracture. Two adult patients with olecranon fractures needed a change in treatment. In the 1138 patients without full elbow extension, 521 fractures were identified. Overall, the test had sensitivity and specificity (95% confidence interval) for detecting elbow fracture of 96.8% (95.0 to 98.2) and 48.5% (45.6 to 51.4). Full elbow extension had a negative predictive value for fracture of 98.4% (96.3 to 99.5) in adults and 95.8% (92.6 to 97.8) in children. Negative likelihood ratios were 0.03 (0.01 to 0.08) in adults and 0.11 (0.06 to 0.19) in children. Conclusion The elbow extension test can be used in routine practice to inform clinical decision making. Patients who cannot fully extend their elbow after injury should be referred for radiography, as they have a nearly 50% chance of fracture. For those able to fully extend their elbow, radiography can be deferred if the practitioner is confident that an olecranon fracture is not present. Patients who do not undergo radiography should return if symptoms have not resolved within 7-10 days.

ObjectiveTo understand decision-making when bringing a child to an emergency department.DesignA cross-sectional survey of parents attending with children allocated a minor triage category.SettingEmergency department in South West England, serving 450,000 people per annum.ParticipantsAll English-speaking parents/caregivers whose children attended the emergency department and were triaged as minor injury/illness.Main outcome measuresParental and child characteristics, injury/illness characteristics, advice seeking behaviour, views regarding emergency department service improvement, GP access and determinants of emergency department use.ResultsIn sum, 373 responses were analysed. The majority of attendances were for minor injury, although illness was more common in <4 year olds. Most presentations were within 4 h of injury/illness and parents typically sought advice before attending. Younger parents reported feeling more stressed. Parents of younger children perceived the injury/illness to be more serious, reporting greater levels of worry, stress, helplessness and upset and less confidence. Parents educated to a higher level were more likely to administer first-aid/medication. Around 40% did not seek advice prior to attending and typically these were parents aged <24 and parents of <1 year olds. The main determinants of use were: advised by someone other than a GP; perceived urgency; perceived appropriateness. The need for reassurance also featured.ConclusionsThe findings suggest that it is difficult for parents to determine whether their child’s symptoms reflect minor conditions. Efforts should focus on building parental confidence and self-help and be directed at parents of younger children and younger parents. This is in addition to appropriate minor injury/illness assessment and treatment services.

The COVID-19 pandemic has produced significant changes in emergency medicine patient volumes, clinical practice, and has accelerated a number of systems-level developments. Many of these changes produced efficiencies in emergency care systems and contributed to a reduction in crowding and access block. In this paper, we explore these changes, analyse their risks and benefits and examine their sustainability for the future to the extent that they may combat crowding. We also examine the necessity of a system-wide approach in addressing ED crowding and access block.

Objective:  Focused assessment with sonography for trauma and emergency ultrasound for abdominal aortic aneurysm are now practiced widely by non‐radiologists in emergency departments worldwide. Various credentialling programs have been proposed for novice sonographers; however, their feasibility has been questioned. We adopted the Australasian College for Emergency Medicine (ACEM) credentialling process for emergency ultrasound to determine whether it is feasible for emergency physicians in the Australasian environment. Methods:  Three full‐time emergency medicine specialists and a post‐Fellowship Examination trainee at Auckland Hospital undertook the credentialling process. Results:  All four participants had sufficient scans to complete the process after 16 months. Accuracy for focused assessment with sonography for trauma, 90% (95% CI 83–95%), and abdominal aortic aneurysm, 99% (95% CI 90–100%), is similar to that previously reported. Conclusion:  The ACEM credentialling process for focused assessment with sonography for trauma and abdominal aortic aneurysm is practical and achievable for emergency medicine specialists working in the Emergency Department at Auckland Hospital. Further studies are necessary to determine whether this holds true for other major trauma centres in Australasia.

Proper capacity planning is vital, but is often poorly done. Planning using aggregated data will lead to inadequate capacity. Understanding demand, and particularly the variation in that demand, is critical to success. Analysis of emergency department demand and capacity is the first step towards effective workforce planning and process redesign.

Pressure to achieve arbitrary targets is not a valid improvement strategy and leads to perverse incentives and use of resources, claims Peter Campbell, but Adrian Boyle and Ian Higginson say no alternative exists to keep emergency departments working