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The practice of keeping admitted patients on stretchers in hospital emergency department hallways for hours or days, called "boarding," causes emergency department crowding and can be harmful to patients. Boarding increases patients' morbidity, lengths of hospital stay, and mortality. Strategies that optimize bed management reduce boarding by improving the efficiency of hospital patient flow, but these strategies are grossly underused. Convincing hospital leaders of the value of such solutions, and educating patients to advocate for such changes, may promote improvements. If these strategies do not work, legislation may be required to effect meaningful change.

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Emergency department (ED) crowding has been identified as a major public health problem in the United States by the Institute of Medicine. ED crowding not only is associated with poorer patient outcomes, but it also contributes to lost demand for ED services when patients leave without being seen and hospitals must go on ambulance diversion. However, somewhat paradoxically, ED crowding may financially benefit hospitals. This is because ED crowding allows hospitals to maximize occupancy with well-insured, elective patients while patients wait in the ED. In this article, the authors propose a more holistic model of hospital flow and revenue that contradicts this notion and offer suggestions for improvements in ED and hospital management that may not only reduce crowding and improve quality, but also increase hospital revenues. Also proposed is that increased efficiency and quality in U.S. hospitals will require changes in systematic microeconomic and macroeconomic incentives that drive the delivery of health services in the United States. Finally, the authors address several questions to propose mutually beneficial solutions to ED crowding that include the realignment of hospital incentives, changing culture to promote flow, and several ED-based strategies to improve ED efficiency. ACADEMIC EMERGENCY MEDICINE 2010; 17:840-847 ª 2010 by the Society for Academic Emergency MedicineKeywords: crowding, financial management, hospitals, outcome and process assessment (health care) E mergency department (ED) crowding is a problem that affects the majority of U.S. hospitals. 1 However, in most hospitals, ED crowding is not a constant phenomenon, but a cyclic one. At certain times of the day and week, there are insufficient space and human resources to care for new ED patients.2 In a 2009 study of Pennsylvania EDs, 83% of medical directors agreed that ED crowding was a problem in their hospitals, but most reported that their EDs were crowded less than 25% of the time and that fewer than 25% of patients who were admitted were delayed for more than 4 hours.3 ED crowding has also been associated with compromised patient care and safety. Crowding is associated with delays in antibiotic therapy in pneumonia, 4 delays in care for acute myocardial infarction 5 and many urgent and emergent conditions, 6-9