Conclusion: This study identified the increased demand placed on a tertiary referral public hospital emergency department during extreme heat events and the potential for overcrowding. Overcrowding has been shown to adversely affect patient service and care, fostering patient and caregiver dissatisfaction as well as lowering quality of care metrics, such as: time to pain control and time to antibiotic care and even increasing mortality. Methods: Stakeholder views on ED operational challenges can provide insights to the major challenges, their causes and ways of overcoming those challenges. Additionally, differences in perceptions between the stakeholders may themselves present a challenge. Face to face semi-structured interviews were conducted with 51 ED head nurses, ED directors and hospital directors of the 17 busiest EDs in Israel.Results: "Overcrowding" was assessed by interviewees to be the most prevalent and acute operational problem, followed by prolonged waits and lengths of stay. Interviewees considered overcrowding a symptom of other operational difficulties, but also a cause of additional operational and clinical difficulties. While few interviewees attributed operational difficulties to suboptimal process management and decision making, many suggested improving operations management, within the ED and in its hospital interactions as promising interventions. Despite agreement on most topics, a major view difference between ED and hospital managers concerned the importance of interventions to minimize ED boarding. Conclusion: All three interviewee groups mostly agreed with each other and with the recent literature regarding operational challenges and their causes. Disagreement was noted regarding minimizing ED boarding. Most interviewees suggested improving operations management within the ED and in its interfaces with the hospital.