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6 Steps to Eliminate Crowding in Your Emergency Department

Why fixing the ED is difficult, but not impossible.

Patients going to the emergency department (ED) often experience long waits to be seen. This has been the case for decades. But why is this still such a hard problem to fix? Your hospital may have created internal teams dedicated to fixing patient flow, embraced Lean, replaced clinical leaders, renovated and expanded the emergency department (at considerable cost), and still the problem persists.

Of all places in the hospital, the ED has the largest patient volume and complexity. Patients range in age from birth to over 100 years old, and all have different acuities, ranging from cardiac arrests to the worried well. Of course, there is no appointment scheduling, and the ED runs 24/7. With the dozens of processes in the ED, it’s hard to know where to start to affect change. Pick the wrong project to attack, and even if you’re successful, you won’t achieve a meaningful reduction in length of stay.

Demand-to-Capacity Matching

Assessing demand requires more than just looking at hourly patient arrivals. One must also look at acuity because workload is a combination of the two. And you can’t ignore variability. While the average patient arrivals might be 100, the range could be between 50-150. If one simply staffs to the average, your team can be understaffed more than not.

For well over a decade, ED patient acuity has been steadily rising, with fewer ESI 4 and 5 patients and more ESI 2 and 3s. (ref. 1) Yet, there was little recognition of this from a staffing perspective. Then along came the COVID-19 pandemic, bringing with it dramatic swings in not only patient volumes but also acuity. As a result, ED admission rates are up, along with ED boarding. This failure to address acuity has resulted in overworked and burned-out nurses, with many leaving the field altogether. Some advanced practice providers (APPs) are now thinking about leaving the ED as well.

Applying Lean to Critical Servers

There are three critical servers or resources in every emergency department: nurses, providers (doctors and APPs), and treatment beds. Those three servers must be matched to demand to achieve efficient patient flow and minimize wait times. Think of a restaurant, where you have tables, wait staff, and the kitchen. If the kitchen cannot prepare the food quickly enough to match the orders, no amount of waitstaff will be able to turn over the tables. Conversely, if there is insufficient waitstaff to take orders and serve the food, it makes no difference if the kitchen has excess capacity.

Such is the case with providers, nurses, and beds. Facilities are short on nurses right now. Without enough nurses, it makes no difference how many providers or beds one has, since the lack of nurses will be the rate-limiting bottleneck. However, unlike a restaurant, an emergency department cannot choose to close on certain days of the week or turn patients away (although that is what we effectively do when we make patients wait six or more hours to be seen). Instead, hospitals stretch their nursing staff by increasing patient ratios or ignoring the acuity factor. Neither is an effective nor sustainable solution.

When a critical server falls short of patient demand, there are only two options:

  1. Increase the server supply: hire more nurses and providers or create more treatment spaces.

  2. If you cannot increase the server supply, as is the case with nurses right now, then one must “Lean Up” the server: remove unnecessary tasks and activities where possible to increase the functional capacity. Consider the use of nurse extenders and creating an RN-led team. (ref. 2)

Never been there or done that

Most clinical leaders spend their entire careers at one or two institutions. They may have never worked in an efficiently run ED, much less turned one around. Imagine that you are a home cook. You’ve never worked in a professional kitchen or taken any cooking classes. Your VIP dinner guest would like you to make a soufflé. You’ve never made one before, don’t have a recipe, and there are no YouTube videos for you to watch. What is your likelihood of success? Such is the case with turning around an ED, which explains why hospital throughput committees can meet for years and not move the needle on patient length of stay.

Continuous Improvement

The biggest misperception is that fixing patient throughput is a one-and-done effort. Historically, patient volumes and acuity have changed over time, and there is no reason to believe this will not continue in the future. Monthly key performance indicators (KPIs) are like a bathroom scale; it will tell you if you are getting worse (e.g., gaining weight) but not why (what and how much food are you eating). What you need are performance metrics on the critical bottlenecks to patient flow. And like weight control, it is much easier to course correct when you notice that you’ve gained 5 pounds as opposed to when you are 25- or 50-pounds overweight. Similarly, it is much easier to fix length of stay when it ticks up 5 or 10 minutes than when it has increased by an hour.

To improve patient flow in your ED and keep it there:

  1. Conduct a precise analysis of your facility’s demand-to-capacity capabilities.

  2. Determine the resources that are essential for meeting patient demand—now and in the future.

  3. Address critical server shortfalls relative to your demand.

  4. Thoroughly assess your clinical leadership team. Do they have the experience and knowledge to plan and execute a turnaround? If they do not, get them the support that they need.

  5. Implement a data-monitoring system that focuses on the key activities that affect patient flow. (Not to be confused with KPIs.)

  6. Respond quickly when volume or acuity changes. Don’t wait until things are out of control.


  1. Trends in Emergency Department Visits, 2006-2014, Healthcare Cost and Utilization Project, Statistical Brief #227, Sept. 2017

Joe Twanmoh, MD, MBA, is the President and Founder of Queue Management. At Queue Management, demand-to-capacity matching and modeling are at the heart of what we do. To learn more, visit

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