Background and Significance of the Problem

Despite living in a century marked by breakthrough lifesaving technologies, overcrowding remains the single most serious safety problem endangering patients in the emergency room. Crawford and colleagues (2014) While the problem is historical, the attributive effect of the problem in emergency medicine was highlighted in 2007, when the IOM warned that the American urgent care system was on the danger of collapsing. Kang and DeFlitch (2014) demonstrate the revelation by arguing that overcrowding has harmed both organizational effectiveness and safety. Given the current demographic and epidemiological shifts where the number of elderlies is growing, and disease chronicity is worsening, the problem is expected to keep soaring. The bleak picture is also captured in Aiken et al. (2012) views, where he suggests that the increasing expectations of health users and austerity measures to cap public spending on health through cost-sharing will further strain the EDs.

The development could jeopardize recent public health gains of improved clinical outcomes, reduced average length of hospital stay, low incidents of iatrogenic infections, readmission rates, as well as well as the provision of result-oriented urgent care. While negative implications remain one the best-explored research concepts, underlying issues are contentious. For instance, while nonurgent users and uninsured people have traditionally been blamed for the ED crisis, a 2016 report by the University of California categorized the line of argument as mythical (Bohan, 2016). The exploration suggested that policymakers, administrators, and health advocates were missing on the real causes of insufficiency and optimality concerns in the ED by blaming the two groups, an aspect that has culminated to the perenniality of overcrowding. The practice issue has resulted in safety and capacity concerns, where the ED is ill prepared to handle patients as well as surges in the event of disasters (Bohan, 2016). While ED crowding remains a high-politics issue, it can be addressed by a raft of approaches. However, there is a need for need for addressing gaps and inadequacies current body of knowledge as per this exploration, where the focus will be factors revolving around health users and systemic organization, and their role in the current ED crisis.

Statement of the Problem Statement

In an age where patient satisfaction has emerged as an important appraisal tool in service delivery, overcrowding has become a major public health issue in the emergency medicine. A key concern remains the implications on the quality of urgent care, with experts noting that overcrowding is underlying in the growing burden of adverse outcomes. The inadequate facilities that characterize overcrowded emergency departments aggravate the risk of medical errors when caregiving processes are executed in the hallway (Crawford et al., 2014). It also contributes to delayed treatment, one of the underlying factors of preventable deaths and complications at the emergency departments. Besides the plight of patients, overcrowding also significantly disrupts the optimality of health care organizations. One of the widely documented aspects is ambulance diversion, which is a major setback in achieving high-performance parameters such as clinical excellence and timeliness. Overcrowding also has an adverse implication on the wellbeing of caregivers, as it contributes to work-related stress. Despite the widely-explored deleterious impacts, underlying reasons have remained a subject of enormous commentary, with the current stock of literature expressing significant inconsistencies, gaps, and conflicting views, a shortfall that informs the need for this exploration.

Literature Review

The 21stcentury has witnessed some of the most innovative healthcare developments, where patient experience has emerged as a critical policy issues. In the midst of the changes, hospitals are engaging in a number of benchmarking programs to improve patient-centered care. Anhang Price et al. (2014) also note that hospitals are in the front line of embracing IOM’s six chasms of quality care, with the central area of focus being equity, effectiveness, timeliness, safety, efficiency, as well as patient-centeredness. Despite the massive investments to attain high-performance status and better clinical outcomes, hospitals continue to be on the receiving end of the Centers for Medicare and Medicaid Services’ Hospital Consumer Assessment of Healthcare Providers and Systems. The poor rating has affected not only the remuneration of individual doctors but also facilities where they receive fewer funds from the federal government. While a number of factors are underlying in the poor scores, Caldwell, Srebotnjak, Wang, & Hsia (2013) suggest that inefficiencies in the emergency department are among the leading factors in negative patient experience.

Although the problem is historical, where it was first highlighted in the 1950s when scholars advised emergency departments to prepare for future turbulence by sophisticating the service delivery approaches, Kang, Nembhard, Rafferty, & DeFlitch (2014) note that the issue has remained overlooked. However, the issue has resurfaced in the 21st century after expert-led reports suggested that overcrowding resulted in hazardous environments that threatened not only the safety of patients but also that of providers (Derlet & Richards, 2000). The supposition is supported by a number of media reports, where patients have turned violent and assaulted providers. However, Shiina (2015) notes that the issue of patients’ violence has remained an ignored criminological issue. Nevertheless, overcrowding is a major safety issue in the delivery of care, an aspect that has informed a number of consultative meetings and conferences (Crawford et al., 2014).

The criticality of overcrowding in the emergency medicine was highlighted by a 2007 IOM report, where the agency noted that the hospital-based urgent care was on the verge of breaking. The view is expressed by Kang & DeFlitch (2014), who note that overcrowding has affected both organizational performance and safety aspects. Sun et al. (2013) also note that the development could jeopardize public health gains in the provision of result-oriented urgent care. Another aspect is the negative implications on the quality of urgent care, with experts noting that overcrowding is underlying in the growing burden of adverse outcomes. Overcrowding in the emergency departments aggravates the risk of medical errors when caregiving processes are executed in the hallway (Crawford et al., 2014). It also contributes to delayed treatment, one of the underlying factors of preventable deaths and complications at the emergency departments. The overcrowding in the emergency departments also affects the timeliness in responding critical illness, a challenge that exemplified by delayed diagnosis and treatment (Derlet & Richards, 2000). Overcrowding also lengthens the waiting times, an issue that may force some health users to leave without being attended by providers.

Besides having a significant toll on personal wellbeing, complications and premature deaths have socioeconomic implications. Overcrowding also significantly disrupts the optimality of health care organizations. One of the widely documented aspects is ambulance diversion, which is a major setback in achieving high-performance parameters such as clinical excellence and timeliness. Overcrowding also has an adverse implication on the wellbeing of caregivers, as it contributes to work-related stress (Derlet & Richards, 2000).

Despite the widely-explored harmful impacts, underlying reasons have remained a subject of enormous commentary, with the current stock of literature expressing significant inconsistencies and multiple views, an aspect that made evidence-based responses a challenge. The problem is captured in Derlet & Richards’ (2000) argument that current responses only offer temporary improvement, an aspect that has made overcrowding more threatening. The views are exacerbated by the contemporary developments, where overcrowding has emerged as a criminological issue and security threat (Derlet & Richards, 2000).

While it is a widely acknowledged concept that overcrowding in the emergency department has multiple effects that touch on clinical as well as non-clinical aspects, the problem remains persistent in the 21st century, over 50 years since it was first highlighted. The continued prevalence of the problem raises critical questions, which are self-defeating why the country has continued to invest in emergency medicine when a seemingly simple issue continues to jeopardize public health gains. The deleterious impacts necessitate the need for huge financial commitment from the federal and state government as well as managerial changes by local hospitals. Derlet & Richards (2000) note that issue is complicated and need cooperation from all stakeholders, not only to uphold the fame that has been associated with EDs but also to respond to the growing demand for urgent care.

Summary of the Evidence for the Proposed Study

While the current body of evidence expresses concordance on adverse implications of overcrowding, the causes have remained contentious, with several camps of scholars highlighting various line of thinking. For instance, while Lo et al. (2014) argues that many emergency departments do not have the capacity to offer the services sufficiently, the issue has elicited a scholarly debate. Lo et al.’s (2014) observation is supported by attendance statistics, where the number of health users visiting in the emergency has soared by over 800% in the last 50 years. The view is supported by Trzeciak (2003), who suggests that the growing number of uninsured population in American has overburdened the health care system. The observation is also echoed in Strike et al. (2014) view that the uninsured and other vulnerable groups such as the homeless have partially contributed to the problem of overcrowding. The assumption arises from the approachability of the ED, especially during winter when the economically disadvantaged groups go to the facilities for not only care but also basics such as food and shelter. However, the arguments are disputed by Manya Newton, a respected clinical instructor at the University of Michigan as well as well as a scholar working with Robert Wood Johnson Foundation, who notes that the problem is a systemic issue that cannot be blamed on any subset of the population. In critiquing the assumption, Newton (2008) notes that even countries with Bismarckian systems where social protection is the most important tenet are also struggling with overcrowded EDs.

Newton (2008) proposes a new line of thinking where he points out that the demographic changes where the number of the elderly is rising as well as the epidemiological shift where the prevalence of chronic diseases has soared should be blamed for the precarious situation in the EDs. The views are supported by a 2010 study, where the New England Healthcare Institute reported that the structure of EDs is not modeled to address the need for the patients. The aspect is highlighted by the trend of shutting down emergency facilities as well as other problems such as understaffing and challenges in seeing primary care physicians. The problems have contributed to inefficiencies, with taxpayers losing $38 billion on an annual basis. Unnecessary care also affected the quality of service delivered because of overcrowding (NEHI, 2010). The financial implications have informed the need for embracing user charges, where experts are considering lowering public expenditure on social services (Stuckler, Basu, & McKee, 2010). However, the move will further strain the delivery of emergency services rather than solve the problem.

Research Question, Hypothesis, and Variables with Operational Definitions

Research Questions

What is the effect of systemic and institutional inadequacies on the problem of ED overcrowding?

What is the role of patient-based factors in the perenniality of overcrowding in the emergency departments?


Null Hypothesis

Systemic and patient-level factors are not underlying in the perenniality of overcrowding in the emergency departments.

Alternative Hypothesis

Systemic and patient-level factors are underlying in the perenniality of overcrowding in the emergency departments.


Independent Variables:

Systemic/institutional factors

Personal-level factors

Dependent variable:

ED Overcrowding

Operational Definitions

Overcrowding: The flow of health users beyond what the ED can handle

Emergency Department: Facilities or sections of primary care organization dealing with the delivery of urgent care.

Patient-level factors: Aspects linked to health users and responsible for straining the EDs.

Systemic/Institutional Factors: Organizational and policy issues underlying in the optimality concerns facing the EDs.

Theoretical Framework

Overview and Guiding Proposition Described in Theory

Queuing theory is one of the most valuable tools for justifying the need for the exploration and explaining the public health concern of overcrowding in the emergency department. The proposition is a statistical model that likens ED to a processing unit comprising of input, throughputs, and outputs (Reese, Silverman, Wu, & Pregerson, 2015). The perspective is built on the systemic thinking, where despite elements such as a dual line of authority and independence of providers in the ED, they function as a single body. Any inadequacy on any part results in clogging of the system. Nevertheless, the theory recognizes the randomness and variability that characterizes all health care organizations by acknowledging that ED cannot be compared to industrial models. Instead, the theory suggests that EDs have a complex structure that is characterized by subsystems and many moving parts. While any ecology can affect the flow in the system, the behavior is non-linear where the input is unproportioned to output (Reese, Silverman, Wu, & Pregerson, 2015). Similarly, the system is self-organizing and keeps exhibiting new behaviors, an aspect that results in unpredictability. Unforeseen occurrences culminate to variability, where the patients are the cog of changeability.

Application of Theory to the Study’s/Project’s Focus

The queuing theory is important in the exploration because of its comprehensiveness. It explores the concept of ED overcrowding from causes, effects, and solutions. One of the most critical views is on the efficiency, where the theory argues that EDs are open systems. While the primary focus of the project is to qualitatively explore the underlying factors in the perenniality of overcrowding in the ED, the current stock of literature confirms the spillover effects of the causes. Despite the negative implications, scholarly undertakings also acknowledge the existence of solutions. Although hypothetical, the links between cause, effects, and interventions are fundamental to the holistic development of the ideas, which is backed by the queuing theory. According to the proposition, systemic and institutional level elements such as underfunding and misprioritization have far-reaching effects in the inefficiencies in the delivery of urgent care. Guest (2013, p.278) also notes that the current curriculum and training modality of health professionals have overlooked the issue and thus the practitioners being produced are ill-prepared to resolve emergent issues. The multifactorial factors have culminated to a number of adverse outcomes such as increased average length of hospital stay, complications, preventable deaths, poor quality clinical care, impaired access to emergency medicine, as well as prolonged suffering, an observation that is supported by the stress management theory and theory of everything.

While patient-level factors have also contributed to the ineffectiveness of the system and capacity challenges, they should not be blamed as any high-performing system should not only predict consumption patterns but also restructure their operations to address new trends. Nevertheless, the supposition highlights the need for change, an issue that is confirmed by the current demographic and epidemiological developments, where expectations of health users have been increasing, the prevalence of chronic disease is soaring, and the population is aging. One theory that offers light in addressing the challenge is Queueing Theory, which notes that the issue can be dealt with through addressing current gaps in managerial approaches, policies, and resource allocation (Hoot & Aronsky, 2008).



The survey focuses on collecting data from providers working in the ED and administrators. The centrality of the two groups has been informed by the knowledge, which will allow them to offer expert responses and opinion on both patient-level and systemic/institutional level factors underlying in ED overcrowding.

The setting of the study is emergency departments. The choice is informed by the specialization in urgent care, where the users are patients without appointments, individuals with indivertible health needs, as well as persons purchasing care by their own means. The three aspects make determining the flow of users highly challenging, with the implications of unpredictability being evident in the vanquishment of benchmarks and current approaches.

Sampling Strategy

The sample size will be determined by Fischer's (1998) formula as indicated below


n= Sample size

Z = Standard normal deviate (1.96) which corresponds to 95% confidence interval.

P = Proportion of occurrence of the variable of focus (which is 0.5 where the figure is not known).

Q =The proportion of non-occurrence of the variable of interest (which is 1-p =0.5)

d= Degree of accuracy = 0.05

The adoption of Fischer’s (1998) method helps in promoting transferability as well as generalizability. Random sampling will then be employed in recruiting the participants, with the approach being preferred because of its strength in ensuring heterogeneity, thus representability (Robinson, 2014).

Research Design

The survey will be a descriptive cross-sectional design. Simon recommends the utilization of the approach in population-based studies, noting that it allows the researcher to explore more than one variable Simon (2003, p.192). The cross-sectional approach is also time-saving and convenience in collecting a vast amount of data from a significant number of respondents. The adoption of the design is also critical in exploring lived experiences, perceptions, attitudes, as well as behavioral aspects, qualitative aspects that will be the center of this study.

The study is based on a positivist paradigm, where personal experience will shape the discourse of the research. Respondents will be treated as the experts, where the study will collect data on factors that are underlying in ED overcrowding. While the research approach poses the challenge of data classification, a pre-tested interviewer-administered semi-structured questionnaire will be used to limit themes of the study and provide an opportunity to clarify uncertainties that may arise during data collection process. The descriptive approach will also ensure the study assess the roles of systemic and patient-based elements without intervening in the occurrence of events.

Extraneous Variables and Controls

Extraneous variables are elements that are not part of the study but have the potential to influence the outcomes. They should be controlled as they can be a source of bias and questionable results. While the study acknowledges that ED overcrowding is a multifactorial subject arising from a number of issues across the health system, it also recognizes the existence of myths as well as intervening factors that have been linked with the dysfunctions in the emergency department. One such aspect is situational elements such as demographic issues where the number of aged is increasing and the growing chronicity of diseases. The undesired influence of the confounding variables is highlighted by a longstanding view of ED, where Sabzghabaei et al., 2015) note that hospital section was designed to offer diagnosis and treatment in a way that allows a continuous flow of health users, a centrality that should not be influenced by population-based changes.

The undesirable effects will be controlled through homogenization of the sample, where old age and chronicity of the disease will be purposely screened out. The control will not only reduce the influence of extraneous variables but will also promote the robustness of the study by increasing external validity, where only systemic and personal-level factors will be explored. Similarly, the data collection procedure will address the external influence by adopting CEDOCS tool to sieve out emergent elements that are necessarily not linked to the organizational and operational issues of health care system. Based on the CEDOCS, alterable factors underlying in ED overcrowding are time variables such as average waiting time and scaling elements, and count variables such as the number of health users in the waiting hall, critical cases in the emergency rooms, as well as total patients who visit the facility, including those who never receive the services. The third category recognized by the CEDOCS is the number of ED beds as well as annual visits.

Another extraneous variable in the study is episodic events responsible for short-term swell up in the inflows of patients such as accidents. While such incidences contribute towards overcrowding and inefficiencies in the handling of the health users, they will be treated as confounding factor as such occurrences can overwhelm even the most dynamic healthcare organization. The influence will be controlled through the randomization, where health providers from different EDs will be given equal statistical chances of participating in the study (Hulley, Cummings, Browner, Grady, & Newman, 2013). Similarly, the catchment area of the survey will be broadened to ensure diversity and reduce the influence of specific events, advantages that will be enhanced by extending the time set for data collection. Allowing the process to take place for an extended period minimizes the Berksonian influence, where short-term situational issues shape the findings. The research will also ensure that the participants do not have a pre-knowledge of the contents of the instruments by collecting data from neighboring EDs on different days.

Instruments: Description, Validity, and Reliability Estimates

The device to be used in the study is a structured questionnaire, which will be complemented by CEDOCS tool in estimating the severity of ED overcrowding. The applicability of the research instruments is ascertained by the reliability and validity estimates. The process of reducing errors through control of extraneous variables and pilot study will determine the applicability of the tools. The stability of the research instruments will be evaluated by the reliability estimates and the intended purpose. The primary goal of determining the applicability of the device is to improve the research outcomes.

With the instrument being adopting from existing stock of literature, internal consistency will be promoted by test-retest and the observer tests. Besides ensuring the suitability of the tool, the reliability estimates help in improving accurateness of data (Yarnold, & Soltysik, 2016). The observer reliability ascertains the choice of the instruments. The validity estimates that have been adopted are the operationalization of the research objectives, a move that has been strengthened by controlling extraneous variables. The external validity determines the extent to which the results of the study can be generalized from the sample to the population of interest while content validity measures elements explored by the research instrument. It will be achieved by taking representative questions from the sample of respondents and measuring them against the desired outcomes. On the other hand, reliability measures the consistency of the instruments.

Crohn Bach’s alpha test will be used to enhance the reliability of the test instrument. The reliability and validity of the generated instruments will be strengthened by conducting a pilot study to determine the appropriateness of the tools and their consistency. Changes will be made according to the identified gaps. Besides, the device will be compared with others that have been used to conduct similar studies. Critiquing is crucial to enhancing the validity of the tools by looking at their illustrations including their limitations.

Description of the Intervention

The intervention focus is documenting factors underlying in ED overcrowding, with providers working in the ED and administrators being the respondents. The rationale is informed by the need for expert-based opinions to counter the myths and unfounded anecdotal views that have resulted in the perenniality of the problem.

Data Collection Procedures

The study seeks to collect data from providers working in the ED and administrators in a virtualized approach, where structured questionnaires will be emailed. Telephone calls will complement the process. CEDOCS tool will be used in the sorting stage to determinant whether participants’ responses culminate to overcrowding. The data collection procedure will entail keying in inputs as informed by the tool and allowed it to determine the level of severity (score above level 4), and then document the underlying factors in an individualized approach.

Data Analysis Plan

Demographic Variable

With descriptive statistics being the most critical stage of data analysis, the first element in understanding the trends in responses will be creating distribution tables. The graphical representations will also be backed up by measures of proportionality, where the frequency and percentages will be the base of describing the participants and response rate in the study.

Study Variables

Besides establishing frequency distribution tables based on sex, age, professional alignments, and years of experience, another informative description of the study variables will be measures of central tendency to show averages as well as measures of dispersion to highlight differences among the categorical data. The approach will provide perspicacity that will shape the focus of inferential statistics (Mertler & Reinhart, 2016).

With overcrowding being a multifactorial issue in the health sector, the study expects many problems to be highlighted as underlying in the perenniality of the problem at both systemic/institutional level and patient-level. The complexity makes crosstabs an important device of the exploratory research, where they will be used to explore bivariate relationships. Unlike frequency tables that capture only one study aspect, cross tabulation allows qualitative explorations among many variables. Their strength in generating axis specification will be exploited in comparing intra-variable and inter-variable results. The descriptive analysis will provide foreknowledge on patterns dataset as well as isolating distinctive takeaways from the responses. Crosstabs will also harmonize results of the demographic and study variables in one diagrammatic representation.

Other relevant inferential statistics will be cluster analysis and chi-square. Chi-square will allow exploring the strength of association while cluster analysis will allow segmenting and identifying structures within the dataset (Kaufman & Rousseeuw, 2009).

Ethical Issues

The study will observe the informed consent rule, where participation in the study will be based on willingness. Respondents will be allowed to be the decision on taking part in the research after non-coercively exploring benefits and risks linked to the study. Similarly, approval will be sought from the IRB as the study is dealing with human subjects.

Limitations of the Proposed Study

While the study seeks to promote trustworthiness through random sampling of participants, the aspect is limited by the desire to observe the ethical value of voluntary participation. Recruitment of respondents will thus be based on willingness to participate rather than strict observation of the sampling frame.

Implications for Practice

ED crowding has remained a critical policy issue because of its perenniality. While a raft of approaches can address the problem, conflicting findings on the causes of ED influx have made it impossible to embrace a harmonious evidence-based solution. The exploration will have practice and professional impacts. On practice, I will promote robustness of the current body of evidence on causes of ED crowding and allow evidence-based responses through expanding hospital capacity, addressing overutilization of emergency care, investing in primary health strategies such as nurse-managed clinics, and embracing evidence-based guidelines in admission patterns.

The exploration will also have positive impacts on personal growth in realizing the professional potential of Master’s prepared nurses. A motivating aspect in the investigation is that the idea of a solution is tenable, as evidenced in Spain and Italy, where the governments have been able to address wastage and ineffectiveness in emergency departments. While such a fete can also be achieved in the United States, there is a need for resolving inconsistencies in the body of evidence in a scholarly approach, and this provides an opportunity for career growth.


Aiken, L. H., Sermeus, W., Van den Heede, K., Sloane, D. M., Busse, R., McKee, M., ... & Tishelman, C. (2012). Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. Bmj, 344, e1717.

Anhang Price, R., Elliott, M., Zaslavsky, A., Hays, R., Lehrman, W., & Rybowski, L. et al. (2014). Examining the Role of Patient Experience Surveys in Measuring Health Care Quality. Medical Care Research And Review, 71(5), 522-554.

Bohan, S. (2016). UCSF study challenges theory on overcrowding – East Bay Times. Retrieved 2 March 2017, from

Caldwell, N., Srebotnjak, T., Wang, T., & Hsia, R. (2013). “How Much Will I Get Charged for This?” Patient Charges for Top Ten Diagnoses in the Emergency Department. Plos ONE, 8(2), e55491.

Crawford, K., Morphet, J., Jones, T., Innes, K., Griffiths, D., & Williams, A. (2014). Initiatives to reduce overcrowding and access block in Australian emergency departments: A literature review. Collegian, 21(4), 359-366.

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Guest, C. (2013). Oxford handbook of public health practice (1st ed., p. 278). Oxford: Oxford University Press.

Hoot, N. & Aronsky, D. (2008). Systematic Review of Emergency Department Crowding: Causes, Effects, and Solutions. Annals Of Emergency Medicine, 52(2), 126-136.e1.

Hulley, S. B., Cummings, S. R., Browner, W. S., Grady, D. G., & Newman, T. B. (2013). Designing clinical research. Lippincott Williams & Wilkins.

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Kang, H., Nembhard, H., Rafferty, C., & DeFlitch, C. (2014). Patient Flow in the Emergency Department: A Classification and Analysis of Admission Process Policies. Annals Of Emergency Medicine, 64(4), 335-342.e8.

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Lo, S., Choi, K., Wong, E., Lee, L., Yeung, R., Chan, J., & Chair, S

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