40 ED crowding: the acceptability of dysfunction

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Crowding in the Emergency Department is internationally recognised as one of the greatest challenges to healthcare provision. Numerous studies have highlighted the ill-effects of crowding, including increased length of stay, mortality and cost per admission. Crowding is typically a manifestation of a hospital at full capacity and its main contributor is the practice of boarding patients in the ED. Therefore, a functioning flow system is advised to ease the burden. Different predictive tools/algorithms assess the degree of crowding. The National Emergency Department Overcrowding Scale (NEDOCS) is used effectively in other countries but has not been validated in Ireland.


Application of the NEDOCS score in the Emergency Department along with the use of internal Patient Administration System (PAS) to track patient movement through the ED.


During the three week period, the NEDOCS score was frequently at level 6 (dangerously overcrowded) or level 5 (severely overcrowded) (see figure 1). Emergency patient registrations peaked between 1000 hours to 1300 hours whereas the peak admission time to wards was between 1900 hours and 2300 hours. At a random time point, Universal staff perception of crowding in the department was perceived as ‘It’s a nice day’. However the NEDOCS level was 4 (overcrowded) suggesting significant crowding.


Our Hospital is operating at a consistent level of crowding that can negatively impact on patients. Access to inpatient beds is available late in the day, creating a time lag between decision to admit and transfer to ward. Staff perception did not correlate with NEDOCs score, possibly reflecting a conditioning and acceptance of staff to crowding.


We plan to validate the NEDOCS score in an Irish Emergency Department. Crowding is a significant issue in the Irish Healthcare setting. The ‘40% of inpatient beds by 11 am’ needs to be adopted by our hospital. Our study suggests that our emergency staff accept the dysfunctional as the norm.

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