Emergency departments (ED) worldwide have experienced dramatic increases in crowding over the past 20 years that now have reached critical levels. One consequence of ED crowding has been the routine use of ED hallways for patient care. This includes ED patients who are awaiting care but are considered unstable to remain in the waiting room, patients who are undergoing active medical and trauma treatment, and patients who have been stabilized but await transfer to an inpatient bed (boarding) or another institution. Compared with licensed hospital or standard ED beds, care in ED hallways results in increased patient morbidity and mortality, as well as patient and staff dissatisfaction. Complications experienced by hallway patients include unrecognized sudden respiratory arrest or unstable cardiac arrhythmias, delay in time-sensitive procedures and laboratory testing, delay in receiving important medications, excessive or unrelieved pain, overall increased length of stay, increased disability, and exposure to traumatic psychological events. While much has been published on the general problems of ED crowding, only recently have studies focused exclusively on the issues of providing care in ED hallways. This review summarizes the current issues, challenges, and solutions for hallway care. 1. Introduction Prior to the 1990s providing care in emergency department (ED) hallways was uncommon, occurring only periodically for short segments of time [1, 2]. Influx of patients generally matched a corresponding outflow, either by discharge home or admission to inpatient units. In some EDs, empty beds were reserved to ensure adequate surge capacity for a sudden influx of patients. In the 1990s, crowding first became a concern in inner city and teaching hospital EDs [3, 4]. Over the next decade the majority of suburban and rural EDs would also experience crowded conditions [5, 6]. As crowding increased, the inflow of patients exceeded outflow for extended hours each day, resulting in the need to place patients somewhere . For a growing number of EDs the solution was to move both stable and semistable patients from licensed ED beds into adjacent ED hallways, thus freeing up the official ED bed for another patient . In these circumstances ED physicians face a difficult challenge. They must provide care to patients in the hallway with suboptimal nursing support and lack of privacy, which precludes a full history and physical examination. Patients may not be able to be fully monitored. Returning new patients back to the waiting room until a licensed ED bed becomes
J. C. Moskop, D. P. Sklar, J. M. Geiderman, R. M. Schears, and K. J. Bookman, “Emergency department crowding, part 1—concept, causes, and moral consequences,” Annals of Emergency Medicine, vol. 53, no. 5, pp. 605–611, 2009.
L. I. Horwitz and E. H. Bradley, “Percentage of US emergency department patients seen within the recommended triage time: 1997 to 2006,” Archives of Internal Medicine, vol. 169, no. 20, pp. 1857–1865, 2009.
R. W. Derlet, R. M. McNamara, A. A. Kazzi, and J. R. Richards, “Emergency department crowding and loss of medical licensure: a new risk of patient care in hallways,” The Western Journal of Emergency Medicine, vol. 15, no. 2, pp. 137–141, 2014.
Department of Health & Human Services (DHHS) and Centers for Medicare & Medicaid Services (CMS), “CMS Manual System Pub 100-07,” 2008, https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R34SOMA.pdf.
T. C. Chan, J. P. Killeen, G. M. Vilke, J. B. Marshall, and E. M. Castillo, “Effect of mandated nurse-patient ratios on patient wait time and care time in the emergency department,” Academic Emergency Medicine, vol. 17, no. 5, pp. 545–552, 2010.
J. M. Nolan, C. Fee, B. A. Cooper, S. H. Rankin, and M. A. Blegen, “Psychiatric boarding incidence, duration, and associated factors in United States emergency departments,” Journal of Emergency Nursing, 2014.
C. van der Linden, R. Reijnen, R. W. Derlet et al., “Emergency department crowding in the Netherlands: managers' experiences,” International Journal of Emergency Medicine, vol. 6, no. 1, article 41, 2013.
K. Danielsen, A. M. Garratt, ？. A. Bjertn？s, and K. I. Pettersen, “Patient experiences in relation to respondent and health service delivery characteristics: a survey of 26,938 patients attending 62 hospitals throughout Norway,” Scandinavian Journal of Public Health, vol. 35, no. 1, pp. 70–77, 2007.
S. Mason, E. J. Weber, J. Coster, J. Freeman, and T. Locker, “Time patients spend in the emergency department: England's 4-hour rule—a case of hitting the target but missing the point?” Annals of Emergency Medicine, vol. 59, no. 5, pp. 341–349, 2012.
W. C. Cha, S. D. Shin, J. S. Cho, K. J. Song, A. J. Singer, and Y. H. Kwak, “The association between crowding and mortality in admitted pediatric patients from mixed adult-pediatric emergency departments in Korea,” Pediatric Emergency Care, vol. 27, no. 12, pp. 1136–1141, 2011.
E. J. Carter, S. M. Pouch, and E. L. Larson, “The relationship between emergency department crowding and patient outcomes: a systematic review,” Journal of Nursing Scholarship, vol. 46, no. 2, pp. 106–115, 2014.
M. L. McCarthy, S. L. Zeger, R. Ding, et al., “Crowding delays treatment and lengthens emergency department length of stay, even among high-acuity patients,” Annals of Emergency Medicine, vol. 54, no. 4, pp. 492.e4–503.e4, 2009.
A. Guttmann, M. J. Schull, M. J. Vermeulen, and T. A. Stukel, “Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada,” British Medical Journal, vol. 342, no. 7809, Article ID d2983, 2011.
S. Jo, Y. H. Jin, J. B. Lee, T. Jeong, J. Yoon, and B. Park, “Emergency department occupancy ratio is associated with increased early mortality,” Journal of Emergency Medicine, vol. 46, no. 2, pp. 241–249, 2014.
J. M. Pines, S. Iyer, M. Disbot, J. E. Hollander, F. S. Shofer, and E. M. Datner, “The effect of emergency department crowding on patient satisfaction for admitted patients,” Academic Emergency Medicine, vol. 15, no. 9, pp. 825–831, 2008.
K. J. Hong, S. D. Shin, K. J. Song, W. C. Cha, and J. S. Cho, “Association between ED crowding and delay in resuscitation effort,” The American Journal of Emergency Medicine, vol. 31, no. 3, pp. 509–515, 2013.
E. B. Kulstad and K. M. Kelley, “Overcrowding is associated with delays in percutaneous coronary intervention for acute myocardial infarction,” International Journal of Emergency Medicine, vol. 2, no. 3, pp. 149–154, 2009.
M. J. Schull, M. Vermeulen, G. Slaughter, L. Morrison, and P. Daly, “Emergency department crowding and thrombolysis delays in acute myocardial infarction,” Annals of Emergency Medicine, vol. 44, no. 6, pp. 577–585, 2004.
C. Fee, E. J. Weber, C. A. Maak, and P. Bacchetti, “Effect of emergency department crowding on time to antibiotics in patients admitted with community-acquired pneumonia,” Annals of Emergency Medicine, vol. 50, no. 5, pp. 501.e1–509.e1, 2007.
J. M. Pines, J. E. Hollander, A. R. Localio, and J. P. Metlay, “The association between emergency department crowding and hospital performance on antibiotic timing for pneumonia and percutaneous intervention for myocardial infarction,” Academic Emergency Medicine, vol. 13, no. 8, pp. 873–878, 2006.
E. B. Kulstad, R. Sikka, R. T. Sweis, K. M. Kelley, and K. H. Rzechula, “ED overcrowding is associated with an increased frequency of medication errors,” The American Journal of Emergency Medicine, vol. 28, no. 3, pp. 304–309, 2010.
U. Hwang, L. D. Richardson, T. O. Sonuyi, and R. S. Morrison, “The effect of emergency department crowding on the management of pain in older adults with hip fracture,” Journal of the American Geriatrics Society, vol. 54, no. 2, pp. 270–275, 2006.
Canadian Association of Emergency Physicians; National Emergency Nurses Affiliation, “Joint Position Statement on emergency department overcrowding,” Canadian Association of Emergency Physicians, vol. 3, no. 2, pp. 82–88, 2001.
A. Boyle, K. Beniuk, I. Higginson, and P. Atkinson, “Emergency department crowding: time for interventions and policy evaluations,” Emergency Medicine International, vol. 2012, Article ID 838610, 8 pages, 2012.
C. C. Won, D. S. Sang, J. S. Kyoung, K. J. Sung, and J. S. Gil, “Effect of an independent-capacity protocol on overcrowding in an urban emergency department,” Academic Emergency Medicine, vol. 16, no. 12, pp. 1277–1283, 2009.
A. Viccellio, C. Santora, A. J. Singer, H. C. Thode Jr., and M. C. Henry, “The association between transfer of emergency department boarders to inpatient hallways and mortality: a 4-year experience,” Annals of Emergency Medicine, vol. 54, no. 4, pp. 487–491, 2009.
J. R. Richards, G. Ozery, M. Notash, P. E. Sokolove, R. W. Derlet, and E. A. Panacek, “Patients prefer boarding in inpatient hallways: correlation with the national emergency department overcrowding score,” Emergency Medicine International, vol. 2011, Article ID 840459, 4 pages, 2011.
B. C. Pulliam, M. Y. Liao, T. M. Geissler, and J. R. Richards, “Comparison between emergency department and inpatient nurses' perceptions of boarding of admitted patients,” Western Journal of Emergency Medicine, vol. 14, no. 2, pp. 90–95, 2013.
O. A. Soremekun, F. S. Shofer, D. Grasso, A. M. Mills, J. Moore, and E. M. Datner, “The effect of an emergency department dedicated midtrack area on patient flow,” Academic Emergency Medicine, vol. 21, no. 4, pp. 434–439, 2014.
D. R. Eitel, S. E. Rudkin, M. A. Malvehy, J. P. Killeen, and J. M. Pines, “Improving service quality by understanding emergency department flow: a white paper and position statement prepared for the American Academy of Emergency Medicine,” The Journal of Emergency Medicine, vol. 38, no. 1, pp. 70–79, 2010.
S. W. Liu, A. G. Hamedani, D. F. M. Brown, B. Asplin, and C. A. Camargo Jr., “Established and novel initiatives to reduce crowding in emergency departments,” Western Journal of Emergency Medicine, vol. 14, no. 2, pp. 85–89, 2013.
A. Yip, S. McLeod, A. McRae, and B. Xie, “Influence of publicly available online wait time data on emergency department choice in patients with non critical complaints,” Canadian Journal of Emergency Medicine, vol. 14, no. 4, pp. 233–242, 2012.
M. D. Bayley, J. S. Schwartz, F. S. Shofer et al., “The financial burden of emergency department congestion and hospital crowding for chest pain patients awaiting admission,” Annals of Emergency Medicine, vol. 45, no. 2, pp. 110–117, 2005.
P. L. Henneman, M. Lemanski, H. A. Smithline, A. Tomaszewski, and J. A. Mayforth, “Emergency department admissions are more profitable than non-emergency department admissions,” Annals of Emergency Medicine, vol. 53, no. 2, pp. 249–255, 2009.
J. M. Pines and J. D. Heckman, “Emergency department boarding and profit maximization for high-capacity hospitals: challenging conventional wisdom,” Annals of Emergency Medicine, vol. 53, no. 2, pp. 256–258, 2009.