Background: During a 6-year period, several process changes were introduced at the emergency department (ED) to decrease crowding, such as the implementation of a general practitioner cooperative (GPC) and additional medical staff during peak hours. In this study, we assessed the effects of these process changes on three crowding measures: patients’ length of stay (LOS), the modified National ED OverCrowding Score (mNEDOCS), and exit block while taking into account changing external circumstances, such as the COVID-19 pandemic and centralization of acute care. Methods: We determined time points of the various interventions and external circumstances and built an interrupted time-series (ITS) model per outcome measure. We analyzed changes in level and trend before and after the selected time points using ARIMA modeling, to account for autocorrelation in the outcome measures. Results: Longer patients’ ED LOS was associated with more inpatient admissions and more urgent patients. The mNEDOCS decreased with the integration of the GPC and the expansion of the ED to 34 beds and increased with the closure of a neighboring ED and ICU. More exit blocks occurred when more patients with shortness of breath and more patients > 70 years of age presented to the ED. During the severe influenza wave of 2018–2019, patients’ ED LOS and the number of exit blocks increased. Conclusions: In the ongoing battle against ED crowding, it is pivotal to understand the effect of interventions, corrected for changing circumstances and patient and visit characteristics. In our ED, interventions which were associated with decreased crowding measures included the expansion of the ED with more beds and the integration of the GPC on the ED.@en

Background Heatwaves have been linked to increased risk of mortality and morbidity and are projected to increase in frequency and intensity due to climate change. The current study uses emergency department (ED) data from Australia, Botswana, Netherlands, Pakistan, and the United States of America to evaluate the impact of heatwaves on ED attendances, admissions and mortality. Methods Routinely collected time series data were obtained from 18 hospitals. Two separate thresholds (4 and 7) of the acclimatisation excess heat index (EHIaccl) were used to define “hot days”. Analyses included descriptive statistics, independent samples T-tests to determine differences in case mix between hot days and other days, and threshold regression to determine which temperature thresholds correspond to large increases in ED attendances. Findings In all regions, increases in temperature that did not coincide with time to acclimatise resulted in increases in ED attendances, and the EHIaccl performed in a similar manner. During hot days in California and The Netherlands, significantly more children ended up in the ED, while in Pakistan more elderly people attended. Hot days were associated with more patient admissions in the ages 5–11 in California, 65–74 in Karachi, and 75–84 in The Hague. During hot days in The Hague, patients with psychiatric symptoms were more likely to die. The current study did not identify a threshold temperature associated with particularly large increases in ED demand. Interpretation The association between heat and ED demand differs between regions. A limitation of the current study is that it does not consider delayed effects or influences of other environmental factors. Given the association between heat and ED use, hospitals and governmental authorities should recognise the demands that heat can place on local health care systems. These demands differ substantially between regions, with Pakistan being the most heavily affected within our study sample.@en

Introduction: Previous studies indicate that crowding scales may not perform well in low-volume emergency departments (EDs). In this study, face-validity of the Modified National ED OverCrowding Score (mNEDOCS) was assessed in a high-volume ED as well as in a low-volume ED. Methods: A prospective observational cohort study was performed in the Netherlands. The correlation of the mNEDOCS with ED staff perceptions of crowding were assessed, using weighted Kappa (κ) and Pearson correlation. Subsequently, ED process measures (elapsed target times to triage, elapsed target times to treatment and patients’ LOS) were described under different levels of ED crowding. Results: Correlation between the categorized crowding scores was low (weighted κ 0.34 resp. 0.26). However, good correlations of 0.73 and 0.82 were found between the uncategorized mNEDOCS and ED staff's perception of crowding. Percentages of patients with elapsed target times to treatment increased simultaneously with increasingly busy periods when measured with mNEDOCS. Conclusions: The uncategorized mNEDOCS correlates well with perceived crowding, even at a low-volume ED. Determining a cut-off level at which a specific ED can be identified as crowded is important, because the predefined mNEDOCS categories may not be optimal for all EDs.@en

Background The impact of delays in emergency department (ED) care has not been described in European countries where ED crowding is not universally recognized. The aim of this study was to determine the relationship of ED crowding with delays in triage and treatment, and 24-h mortality in patients admitted to the ED. Methods Five years of data from adults admitted to the hospital were analysed retrospectively from an inner-city ED in the Netherlands. Variables included the following: crowded versus noncrowded time, time to triage, triage category, time to treatment, age, 24-h mortality and 10-day mortality. Results A total of 39 110 patients met the inclusion criteria. ED crowding occurred 30.8% of the time. There were no differences in mortality between patients arriving during crowding versus those arriving during noncrowding. Delays in triage during ED crowding occurred 29.7% of the time versus 14.6% during noncrowding. Delays in treatment occurred 11.7 and 7.3% of the time during crowding and noncrowding, respectively. Conclusion In this hospital, ED crowding results in increased times to triage and to treatment, not in increased 24-h or 10-day mortality.@en

Background: In The Netherlands, the state of emergency department (ED) crowding is unknown. Anecdotal evidence suggests that current ED patients experience a longer length of stay (LOS) compared to some years ago, which is indicative of ED crowding. However, no multicenter studies have been performed to quantify LOS and assess crowding at Dutch EDs. We performed this study to describe the current state of emergency departments in The Netherlands regarding patients' length of stay and ED nurse managers' experiences of crowding. Methods: A survey was sent to all 94 ED nurse managers in The Netherlands with questions regarding the type of facility, annual ED census, and patients' LOS. Additional questions included whether crowding was ever a problem at the particular ED, how often it occurred, which time periods had the worst episodes of crowding, and what measures the particular ED had undertaken to improve patient flow. Results: Surveys were collected from 63 EDs (67%). Mean annual ED visits were 24,936 (SD ± 9,840); mean LOS for discharged patients was 119 (SD ± 40) min and mean LOS for admitted patients 146 (SD ± 49) min. Consultation delays, laboratory and radiology delays, and hospital bed shortages for patients needing admission were the most cited reasons for crowding. Admitted patients had a longer LOS because of delays in obtaining inpatient beds. Thirty-nine of 57 respondents (68%) reported that crowding occurred several times a week or even daily, mostly between 12:00 and 20:00. Measures taken by hospitals to manage crowding included placing patients in hallways and using fasttrack with treatment of patients by trained nurse practitioners. Conclusions: Despite a relatively short LOS, frequent crowding appears to be a nationwide problem according to Dutch ED nurse managers, with 68% of them reporting that crowding occurred several times a week or even daily. Consultations delays, laboratory and radiology delays, and hospital bed shortage for patients needing admission were believed to be the most important factors contributing to ED crowding.

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