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Abstract.Objective: To describe the definition, extent, and factors associated with overcrowding in emergency departments (EDs) in the United States as perceived by ED directors. Methods: Surveys were mailed to a random sample of EDs in all 50 states. Questions included ED census, frequency, impact, and determination of overcrowding. Respondents were asked to rank perceived causes using a fivepoint Likert scale. Results: Of 836 directors surveyed, 575 (69%) responded, and 525 (91%) reported overcrowding as a problem. Common definitions of overcrowding (>70%) included: patients in hallways, all ED beds occupied, full waiting rooms >6 hours/ day, and acutely ill patients who wait >60 minutes to see a physician. Overcrowding situations were similar in academic EDs (94%) and private hospital EDs (91%). Emergency departments serving populations Յ250,000 had less severe overcrowding (87%) than EDs serving larger areas (96%). Overcrowding occurred most often several times per week (53%), but 39% of EDs reported daily overcrowding. On a 1-5 scale (ϮSD), causes of overcrowding included high patient acuity (4.3 Ϯ 0.9), hospital bed shortage (4.2 Ϯ 1.1), high ED patient volume (3.8 Ϯ 1.2), radiology and lab delays (3.3 Ϯ 1.2), and insufficient ED space (3.3 Ϯ 1.3). Thirty-three percent reported that a few patients had actual poor outcomes as a result of overcrowding. Conclusions: Episodic, but frequent, overcrowding is a significant problem in academic, county, and private hospital EDs in urban and rural settings. Its causes are complex and multifactorial. Key words: emergency departments; overcrowding. ACADEMIC EMERGENCY MEDICINE 2001; 8:151-155 E MERGENCY departments (EDs) provide an extraordinarily important public service mission by providing emergency care 24 hours a day, 365 days per year without discrimination by social or economic status. Of the nation's 5,000 EDs, all have a physician physically present on the premises at all hours who can attend to patients with acute and chronic injuries and illnesses. One of the key foundations of EDs is the ability and expectation to provide immediate access and stabilization for those patients with medical emergencies. Recently there has been increasing discussion regarding the ability of EDs to provide timely care to patients with emergency medical conditions.

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Objectives: No single universal definition of emergency department (ED) overcrowding exists. The authors hypothesize that a previously developed site-sampling form for academic ED overcrowding is a valid model to quantify overcrowding in academic institutions and can be used to develop a validated short form that correlates with overcrowding. Methods: A 23-question site-sampling form was designed based on input from academic physicians at eight medical schools representative of academic EDs nationwide. A total of 336 site-samplings at eight academic medical centers were conducted at 42 computer-generated random times over a three-week period by independent observers at each site. These sampling times ranged from very slow to severely overcrowded. The outcome variable was the degree of overcrowding as assessed by the charge nurse and ED physicians. The full model consisted of objective data that were obtained by counting the number of patients, determining patients' waiting times, and obtaining information from registration, triage, and ancillary services. Specific objective data were indexed to site-specific demographics.

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Overcrowding varied widely between academic centers during the study period. Results of a five-question reduced model are valid and accurate in predicting the degree of overcrowding in academic centers.

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