Emergency department crowding

Crowding in emergency departments is a major patient safety concern since it leads to poor quality of service and patient mortality (Pines, et al, 2011). When care is delayed and patient satisfaction is low, patient safety is jeopardized. In addition to reducing care quality, ED overcrowding is expensive. Overcrowding lowers the quality of care and raises patient safety concerns by injuring patients and reducing the patient care experience (Emergency Nurses Association, 2014).

Patient discontent, inadequate healthcare, and limited access to care are all exacerbated by the increased demand for ED care by patients with non-urgent care needs (Harris, & Sharma, 2010). Studies indicate that the use of nurse practitioners (NP) can reduce emergency Department (ED) overcrowding, long wait times, ease access to care and improve patient satisfaction (Quttrini & Swan, 2011).


Emergency healthcare has reached a crossroads since 1994 in which patient visits to emergency departments have significantly increased. Studies show that patient visits of ED increased by 18 percents between 1994 and 2004 (Shah, et al. 2015). At the same time the number of EDs decreased by 12 percent. According to McGee and Kaplan (2007), overcrowding refers to a situation whereby the need for emergency services surpasses the department's ability to offer quality care. The commonly held definitions for ED overcrowding include "all beds occupied for more than six hours, physicians feeling rushed for six hours, patients placed in hallways, lengthy wait times for acutely ill patients and a full ED waiting room for six hours" (McGee & Kaplan (2007: 44).

ED overcrowding leads to inadequate patient care, patient dissatisfaction, lengthy waiting times, ambulance diversions, delayed treatment of suffering and pain. Lengthy waiting times and patient satisfaction are inversely related. Patients with minor or non-urgent medical problems have longer waiting time (Quttrini & Swan, 2011). ED overcrowding results in numerous consequences such as poor patient outcomes, increased frustration among providers, increased board times, dissatisfied patients and increased ambulance diversion.

A number of EDs are implementing the NP-run fast track to offer care to people who require non-urgent care. NP-run fast track aims to manage patients who require non-urgent care in a timely and effective manner, reduce wait time, decrease ED overcrowding, reduce length of day and increase patient satisfaction (Quattrini & Swan, 2011).

With emergency department overcrowding getting worse, examining how nurse practitioners (NPs) may contribute to addressing the problem is timely. NPs use an interpersonal and holistic approach to healthcare. Care outcomes indicate decreased costs, improved health benefits and patient satisfaction. NPs offer healthcare that decreases waiting times improves patient choices and increases patient access (Shah, et al. (2015)

The ED serves people who are without health insurance cover, cannot easily access care from primary care practitioner or who do not have a primary care practitioner. This forces many of them to seek medical attention for non-emergent health conditions in the ED. Nurse practitioners are well trained and prepared to offer care for non-emergent conditions in the ED environment. With their focus on disease prevention and health promotion, nurse practitioners an essential adjunct to inter-disciplinary groups in EDs. While the role of nurse practitioner has been expanded to ED, little is known about how their experience and skills can best be used in ED.

Problem Statement

The ED is being utilized for care of acutely ill patients on a very limited basis. Of the nearly 14 million patient visits to EDs, only 12.9% are emergent. The remaining majority are urgent, non-urgent or semi-urgent. The small proportion of patient visits to ED categorized as emergent indicates that NPs are well prepared to providing healthcare most ED patients. However, most EDs use only physicians in spite of the fact that NPs are capable of providing quality and cost effective care in ED (McGee & Kaplan, 2007). There are few studies exploring why NPs are not being employed in EDs when their skills, ability and education may help address ED overcrowding, enhance access to care and improve patient satisfaction. Nurse practitioners have the potential to address overcrowding in ED and improve quality of care and patient satisfaction.

While NPs are skilled, educationally prepared and experienced healthcare providers of quality care, they are minimally used in ED environments. Given that the emergency care system provides care to those who lack primary care or are uninsured, it is recorded that NPs can play an instrumental role in reducing care costs and improving efficiency in EDs. Many studies support the role of NP in the delivery of ED care. These studies show that patients are contended with NP care. NPs have better interpersonal skills to serve patients (McGee & Kaplan, 2007). The involvement of NPs in ED contributes to less waiting times and improved quality of care.


Significance the use of NP in ED to serve patients who require non-urgent care will improve quality and safety of care, and access to care. A body of evidence reveals that the satisfaction of ED patients is associated with delayed care delivery. If the use of NP helps reduce overcrowding, decrease wait times, length of stay and consequently improve patient satisfaction, then healthcare organizations will benefit immensely from the findings of this study.

Operational variables

Access is defined as use or entry into the healthcare system. It also characterizes factors determining use or entry such as affordability, availability, accessibility, acceptability and accommodation. Access to care is categorized as a dependent variable. The instrument used to measure access is National Access to Care Survey. The survey contains conceptual questions related to access to care, healthcare use and expenditure. The survey uses the measures such as insurance coverage, use of emergency room, use of ED for non-urgent care.

Patient satisfaction measures the extent to which patients are happy with the care they receive from healthcare providers. It is the measure of a patient's experience in comparison to their expectations. Assessing the extent to which patients are contented with services they receive is relevant as. Patient satisfaction is an important indicator of quality of care. It influences timely and efficient delivery of quality care and clinical outcomes. Patient satisfaction is a construct encompassing several factors, such as personal attributes, financial arrangements, health insurance approval, and convenience of location, resource availability and physician's knowledge.. Patient satisfaction questionnaires will be used to examine patient satisfaction. Four items will be included on the scale include ease access of care, interpersonal skills of NPs, care costs and waiting times.

Patient satisfaction is categorized as a dependent variable. The instrument has good reliability and offer wide scope of survey questions.


The purpose of this proposal is to explore the impact of nurse practitioners in ED in reducing overcrowding and long wait times and consequently improve patient satisfaction and experience.


The question of this research proposal is: How the use of a nurse practitioner in ED will impact patient satisfaction?

Hypothesis: The use of NP in Ed to provide non-urgent care will reduce ED overcrowding, decrease wait time access and increase patient satisfaction

Hull hypothesis: the use of NP in ED will not improve patient satisfaction


Emergency Nurses Association. (2014). Advanced practice nurses in emergency care. Retrieved on January 15, 2017 from http://www.ena.org/practice-research/Practice/Pages/AdvPractice.aspx

Harris, A. & Sharma, A. (2010). Access block and overcrowding in emergency departments: an empirical analysis. Emergency Medicine Journal, 27(7), 508-11.

McGee, L.A., & Kaplan, L. (2007).Factors influencing the decision to use nurse practitioners in the emergency department. Journal of Emergency Nursing, 33, 441-446

Pine, J. M. et al.(2011).ED crowding is associated with variable perceptions of care compromise. Academic Emergency Medicine, 14(12):1176-1181.

Quattrini, V., & Swan, B.A. (2011). Evaluating care in ED fast tracks. Journal of Emergency Nursing, 37, 40-46

Shah, S. C. et al. (2015). Managing patient expectations at emergency department triage. Patient Experience Journal, 2(2): 31-44

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