O’Connor et al.

International Journal of Emergency Medicine 2014, 7:16

http://www.intjem.com/content/7/1/16

ORIGINAL RESEARCH Open Access

Evaluating the effect of emergency department

crowding on triage destination
Erin O’Connor1, Mathieu Gatien1, Cindy Weir1 and Lisa Calder1,2*

Abstract
Background: Emergency Department (ED) crowding has been studied for the last 20 years, yet many questions
remain about its impact on patient care. In this study, we aimed to determine if ED crowding influenced patient
triage destination and intensity of investigation, as well as rates of unscheduled returns to the ED. We focused on
patients presenting with chest pain or shortness of breath, triaged as high acuity, and who were subsequently
discharged home.
Methods: This pilot study was a health records review of 500 patients presenting to two urban tertiary care EDs
with chest pain or shortness of breath, triaged as high acuity and subsequently discharged home. Data extracted
included triage time, date, treatment area, time to physician initial assessment, investigations ordered, disposition,
and return ED visits within 14 days. We defined ED crowding as ED occupancy greater than 1.5. Data were analyzed
using descriptive statistics and the χ2 and Fisher exact tests.
Results: Over half of the patients, 260/500 (52.0%) presented during conditions of ED crowding. More patients
were triaged to the non-monitored area of the ED during ED crowding (65/260 (25.0%) vs. 39/240 (16.3%) when
not crowded, P = 0.02). During ED crowding, mean time to physician initial assessment was 132.0 minutes in the
non-monitored area vs. 99.1 minutes in the monitored area, P <0.0001. When the ED was not crowded, mean time
to physician initial assessment was 122.3 minutes in the non-monitored area vs. 67 minutes in the monitored area,
P = 0.0003. Patients did not return to the ED more often when triaged during ED crowding: 24/260 (9.3%) vs. 29/240
(12.1%) when ED was not crowded (P = 0.31). Overall, when triaged to the non-monitored area of the ED, 44/396
(11.1%) patients returned, whereas in the monitored area 9/104 (8.7%) patients returned, P = 0.46.
Conclusions: ED crowding conditions appeared to influence triage destination in our ED leading to longer wait times
for high acuity patients. This did not appear to lead to higher rates of return ED visits amongst discharged patients in
this cohort. Further research is needed to determine whether these delays lead to adverse patient outcomes.
Keywords: Emergency Department crowding; Emergency Department occupancy; High acuity; Overcrowding; Triage

Background greatly influence the course of the patient’s visit, including

Emergency Department (ED) crowding was first identified time to assessment, extent of workup, and length of stay
as a problem over 20 years ago [1]. Research has since fo- in the ED [2]. Assignment of a triage score, and subse-
cused on the effect of ED crowding on adverse patient quent placement in an non-monitored (less acute) vs.
outcomes; however, the effect of ED crowding on triage monitored (more acute) area of the ED affects physician
destination has not been studied. Triage and the assign- thinking and decision making about the patient’s pres-
ment of the patient to an area of the ED is an important entation [3,4].
part of a patient’s visit to an ED. Triage destination can ED crowding is a concern with regard to patient safety,
as it has been associated with adverse patient outcomes
* Correspondence: [email protected] including increased patient mortality, delayed resuscita-
1
Department of Emergency Medicine, University of Ottawa, 1053 Carling tion efforts, increased adverse events, delayed antibiotic
Avenue, Ottawa, ON K1Y 4E9, Canada administration in patients with pneumonia, and in-
2
Clinical Epidemiology Program, Ottawa Hospital Research Institute, The
Ottawa Hospital, Civic Campus, Rm F658, 1053 Carling Ave., Ottawa, ON K1Y creased in-hospital length of stay [5-10]. ED crowding
4E9, Canada

© 2014 O’Connor et al.; licensee Springer. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction
in any medium, provided the original work is properly credited.
O’Connor et al. International Journal of Emergency Medicine 2014, 7:16 Page 2 of 7
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has also been related to poor management of pain and based on CTAS score, but there is allowance for triage
decrease in patient satisfaction [11-13]. nurse discretion in assignment of patient destination. A
We present a pilot study of patients presenting with CTAS score of 2 (Emergent) is assigned to conditions
chest pain or shortness of breath, triaged as high acuity, that are a potential threat to life limb or function and it
and who were discharged home on the index visit. Our is recommended that patients be seen by a physician
objectives were to determine whether: 1) patients were within 15 minutes 95% of the time [14,16]. We excluded
triaged to non-monitored areas of the ED more fre- patients if they were admitted to the hospital on the
quently during ED crowding; 2) patients were assessed index visit. Patients were not excluded if they presented
by a physician more quickly in non-monitored rather more than once. We divided the patients into cohorts
than monitored areas during crowded conditions; 3) pa- by geographic destination in our department. Non-
tients triaged to the non-monitored area received the monitored patients were those who were assigned to the
same laboratory and imaging tests as those triaged to least acute area of our department. Monitored patients
monitored areas; 4) patients triaged during ED crowding were those triaged to the most acute areas of our de-
received the same laboratory and imaging tests as those partment and were placed on continuous cardiac and
triaged during non-crowded conditions; 5) the propor- respiratory monitoring.
tion of return ED visits was higher for patients triaged A single reviewer (EO) who was not blinded to the study
during ED crowding; and 6) the proportion of return ED hypothesis abstracted data onto a standardized Microsoft
visits was higher for patients triaged to the non-monitored Excel spreadsheet. Data were obtained from the electronic
area during crowded conditions. health record, which contained scanned handwritten nurs-
ing triage notes and physician notes as well as computer-
ized laboratory and imaging results. We recorded the
Methods following variables: triage time and date, triage score, tri-
Study design and setting age destination, time of initial physician assessment, inves-
We conducted a health records review of patients pre- tigations ordered, and referrals made. We also recorded
senting to two ED campuses of a large urban tertiary whether a patient’s destination changed during the ED
care Canadian academic teaching hospital, each with ap- visit. Up-triage was defined as a patient moved from the
proximately 75,000 patient visits per year. We used non-monitored area to the monitored area. Down-triage
International Classification of Diseases 10 codes to iden- was defined as moving from the monitored area to the
tify patient visits corresponding with chief complaints of non-monitored area. Change in triage destination was
chest pain or shortness of breath for the period between made at the discretion of the bedside nurse or treating
January 1st and December 31st 2010. A total number of physician and could occur at any time during the patient’s
4,234 patient visits were identified. Using an Internet-based stay in the ED. We do not have protocols in our ED for
random number generator (http://www.randomizer.org), up-triage based on time to initial physician assessment.
we selected a sample of health records, with an overall
goal of 500 eligible visits. The Ottawa Hospital Research
Study outcome measures
Ethics Board approved this study.
Study outcomes included: triage destination during ED
crowding conditions, time to physician assessment (the
Subjects and data collection
time from patient arrival to assessment by a physician,
We included patients older than 18, who presented with
in minutes), investigations ordered, and unscheduled return
a chief complaint of either chest pain or shortness of
to our institution within 14 days of the index visit.
breath, were assigned a Canadian Triage and Acuity Scale
(CTAS) score of 2, and were discharged home on the
index visit [14]. CTAS is a five-category triage system de- ED crowding measure
signed to allow Canadian EDs to prioritize patients based ED crowding was measured using ED occupancy at the
on their presenting complaint and the severity of their time of patient triage, which was defined as the ratio of
signs and symptoms. Triage nurses who have received total number of patients in the ED (admitted and not
training assign CTAS scores based on a published set of admitted) to the number of beds in the ED [17]. For our
guidelines [14]. CTAS scores are determined by present- department, we included numbers of beds in all areas of
ing complaint, with severity modifiers based on vital signs, the ED, monitored and non-monitored. ED occupancy is
past medical history, and brief history of the complaint an accepted measure of ED crowding, but there is no
[15]. Included in the CTAS score assignment system is universally accepted threshold that defines ED crowding
nursing discretion, allowing for a higher CTAS score to [18,19]. We determined, based on local expert consensus,
be assigned based on the judgment of the triage nurse. that an ED occupancy score of greater than 1.5 would
In our hospital there are guidelines for destination indicate that our ED was crowded.
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Sample size and statistical analysis the included patients were triaged during crowded condi-
A rate of return to our ED in this cohort of patients was tions. Most of the patients were triaged to the monitored
assumed to be 20% (based on previous studies in our de- area (Table 1).
partment) [20]. A difference in return rates of 10% was
deemed significant, resulting in a sample size of 588. In Triage decision making and time to initial physician
this pilot study, the sample size of 500 charts was chosen assessment
for convenience. Descriptive statistics were used to report We found that patients who presented with a chief com-
patient and system characteristics. Univariate analysis was plaint of chest pain or shortness of breath and were
performed with the χ2 test for all dichotomous variables. assigned a CTAS score of 2 were triaged to the non-
The Fisher exact test was used to analyze nominal vari- monitored area of the ED significantly more often when
ables and continuous variables were analyzed with the the ED was crowded (25.0% vs. 16.3%, P = 0.02) (Figure 2).
Wilcoxon two-sample test. The mean time to physician initial assessment was sig-
nificantly longer for those patients triaged when the ED
Results was crowded (107.3 minutes vs. 76.0 minutes, P <0.0001)
Study flow (Figure 3a). The mean time to physician initial assessment
We found 568 eligible health records during the study was significantly longer in the non-monitored area of the
period; 7 visits were excluded for a CTAS score other ED than in the monitored area (Figure 3b). This was
than 2 and 61 charts were excluded based on chief com- found to be true both when the ED was crowded (132.0
plaint. Finally, we included a total of 500 health records minutes vs. 99.1 minutes, P <0.0001) and when it was
in our study (Figure 1). non-crowded (122.3 minutes vs. 67.0 minutes, P = 0.0003).
Patients were not up-triaged more often from the
Patient and system characteristics non-monitored area to a more acute area of the depart-
Over half of the patients were male. Chest pain was the ment when the ED was crowded than when the ED was
most common chief complaint. Approximately half of non-crowded (3.1% (n = 8) vs. 1.3% (n = 3), P = 0.42).

ED crowding and geographical influence on

investigations ordered
ED crowding did not appear to influence the proportion
of patients who received ED investigations with the ex-
ception of more chest computed tomography ordered
when the ED was not crowded (9.2% vs. 5.4%, P = 0.01)
(Figure 4).
Data not depicted in the figures shows that investiga-
tions were influenced by the patient’s geographic location

Table 1 Patient and system characteristics for 500 high

acuity patients presenting with chest pain or shortness of
breath
Patient characteristics n (%)
Male 269 (53.8)
Presenting complaint
Chest pain 392 (78.4)
Shortness of breath 108 (21.6)
System characteristics n (%)
ED crowding status1 at time of triage
Crowded 260 (52.0)
Non-crowded 240 (48.0)
Triaged ED location
Non-monitored 104 (20.8)
Monitored 396 (79.2)
1
Figure 1 Study flow diagram. ED Occupancy = Number of patients in the ED/Number of beds in the ED.
Crowded is defined as an ED Occupancy >1.5.
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Proportion of return visits to the ED

100
Overall, rates of unscheduled returns to our ED were
Proportion of Patients (%)

80 lower than anticipated: 51/500 (10.2%). We did not find

p=0.02 a significant association between ED crowding and the
60 proportion of patients who had an unscheduled return
to the ED within 14 days of the index visit (9.3% vs.
40 25.5% 12.1%, P = 0.31) (Figure 5a). In addition, the difference in
16.3%
20 geographic ED location (non-monitored vs. monitored)
was not significantly associated with an increase in the
0 proportion of patients with an unscheduled return to
Crowded Non-Crowded the ED (11.1% vs. 8.7%, P = 0.46) (Figure 5b).
Figure 2 Proportion of patients triaged to the non-monitored
area during crowded and non-crowded conditions (n = 500). Discussion
Understanding how ED crowding affects patient out-
in the ED, with more investigations ordered in the moni- comes has been identified as a research priority in emer-
tored area of the ED: complete blood count: 99.2% vs. gency medicine [21]. Assignment of a triage score and
67.31%, P <0.0001; electrolytes: 99.4% vs. 64.4%, P <0.0001; destination in the emergency department has an import-
blood urea nitrogen: 99.2% vs. 66.4%, P <0.0001; venous ant impact on the course of a patient’s ED visit [4]. We
or arterial blood gas: 6.6% vs. 1.0%, P = 0.03). Exceptions postulated that the negative impact of ED crowding with
to this were significantly fewer electrocardiograms (86.5% regard to increased patient mortality, increased adverse
vs. 95.5%, P = 0.0009) and D-dimers (26.0% vs. 16.4%, events, and delayed antibiotic administration in patients
P = 0.03) ordered in the monitored area. We found no sig- with pneumonia reported in previous studies may be re-
nificant difference in the number of chest radiographs lated to differences in triage practices during times of
(P = 0.61) and chest computed tomography scans (P = 0.52) crowding [5-10]. We hypothesized that patients would
ordered. More patients received a referral to another ser- be triaged more often to the non-monitored or less
vice, either as an inpatient or as an outpatient from the acute area of our ED when the ED was crowded. We
monitored area (51/396 (12.8%) vs. non-monitored 1/104 theorized that the patients in the non-monitored area
(1%) P <0.0001). would have fewer investigations and the physicians’ per-
ception of the severity of their illness would be nega-
tively impacted [4]. We found that high acuity patients
(a) were triaged to the non-monitored area of the ED more
120
Mean time to physcian assessment

t = 107.3
p<0.0001 often when they presented during crowded conditions.
100
This change in triage destination during crowded condi-
80 t = 76.0
tions may be based on an assumption by the triage nurs-
(minutes)

60 ing staff that patients would be seen more quickly by a

physician if they are not required to wait for a moni-
40
tored bed. This group of patients also received less blood
20 work and fewer imaging tests than those sent to the
0 monitored or more acute area of our ED. The differ-
Crowded Non-crowded
ences in investigations and imaging tests ordered for
these patients is potentially based on the physician’s per-
(b) ception of lower acuity of presentation because the pa-
Non-Monitored
Mean time to physician assessment

140 t = 132.0 p<0.000 tient is in the non-monitored area of the ED. A few of
1 t = 122.3 Monitored
120
t = 99.1
the differences were unexpected, in particular the fact
p=0.0003
100 that fewer ECGs were ordered in the monitored area of
(minutes)

80 t = 67.0 the ED. It is possible that because the patients were on

60 continuous cardiac monitors that 12 lead ECGs were
40 not obtained. Another possible explanation for this is
20 that ECGs performed on these patients were lost and not
0 scanned in to the computer record from which we ob-
Crowded Non-Crowded
tained our data. We speculate that more D-dimers were
Figure 3 Mean time from triage to physician initial assessment ordered in the non-monitored area of the ED because it is
during crowded and non-crowded conditions (n = 500). (a) Overall.
used more as a “rule-out” test. For patients perceived to
(b) Divided by non-monitored and monitored areas.
be more ill, a CT scan may have been ordered to
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(a)
p=0.20 p=0.29 p=0.45
100 p=0.53

Proportion of Patients (%)

91.2% 94.2% 90.8% 93.3% 91.6% 93.3%
86.1% 84.2%
90
Crowded
80
70 Non-crowded
60
50
40 p=0.07
30 p=0.23
21.7%
20 15.4%
4.3% 6.7%
10
0
CBC Electrolytes BUN CK/TnI VBG/ABG D-Dimer

(b)
p=0.08
Proportion of Patients (%)

p=0.81
91.5 95.4 93.9 93.3
100
80
Crowded
60
Non-crowded
40 p=0.01

20 9.2%
5.4%
0
CXR CT Chest ECG
Figure 4 Investigations ordered for high acuity ED patients triaged either to the non-monitored or monitored areas of the ED, presenting
with chest pain or with shortness of breath. (a) Blood-work ordered. (b) Imaging and ECGs ordered. [CBC, Complete Blood Count; BUN, Blood
Urea Nitrogen; CK, Creatinine Kinase; TnI, Troponin I; VBG, Venous Blood Gas; ABG, Arterial Blood Gas; CXR, Chest Radiograph; CT Chest, Chest
Computed Tomography; ECG, Electrocardiogram].

investigate pulmonary embolism with a D-dimer omitted of ED crowding. ED occupancy rate has been shown to
from the work-up. Overall, ED crowding led to more perform as well as the following markers of ED crowding:
high-acuity patients being triaged to the non-monitored EDWIN score, patients left without being seen and ambu-
area of our ED, with fewer investigations performed. lance diversion times [16]. ED occupancy has the advan-
We did not find that ED crowding conditions resulted tage of being calculable for the time of patient triage
in an increase in return visits to the ED within 14 days rather than as an average over the course of a day and
for patients presenting with chest pain or shortness of hence may offer increased precision. In this pilot study,
breath and assigned a CTAS score of 2. Given that we we attempted to specifically examine the effect of ED
experienced overall rates of return that were lower than crowding on triage destination; therefore, a crowding
anticipated, our study may be underpowered to detect a measure specific for the time of triage was felt to be the
true difference. This finding is consistent, however, with most useful. In future work in this area we would measure
previous research by Hu et al., which found no correl- crowding using the EDWIN score, ambulance diversion
ation between unscheduled return visits to the ED and rates, and rates of left without being seen as well as using
ED crowding [22]. We did show an increase in time to ED occupancy.
physician initial assessment for patients triaged during There are several limitations to this study. Firstly, it
crowding conditions. A previous study by Guttman et al. was restricted to a single institution that encompasses
showed a positive correlation between increased waiting two large tertiary care EDs and we were only able to de-
times and admission to hospital or death within 7 days tect return visits to our institution and not to other in-
for discharged patients [23]. stitutions in our area. Previous studies conducted at our
We used ED occupancy rate as our measure of ED center indicate that patients rarely return to other insti-
crowding because it is a parsimonious, valid measurement tutions after an index visit to our ED [20]. Our sample
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(a)
20
18

Proportion of Patients
16 p=0.31
14 12.1%
12
(%) 10 9.3%
8
6
4
2
0
Crowded Non-crowded
(b)
20
Proportion of Patients (%)

15 p=0.46
11.1%
8.7%
10

0
Monitored Non-monitored
Figure 5 Proportion of patients who return to the ED within 14 days of index visit. (a) Patients triaged during crowded or non-crowded
conditions. (b) Returns to the ED by initial triage destination.

size was relatively small, with only 500 health records in- same CTAS score have the same level of acuity and the-
cluded. Previous studies at our institution estimated a oretically then need the same amount of monitoring and
rate of return in this cohort of 20% [20]. However, in the investigation, which may not be true.
group of patients we studied our rate of return was This is the only study so far to examine the impact of
10.2%, meaning that our study was under-powered. We ED crowding on triage destination. A larger, multi-
set a cut-off for ED crowding at an occupancy level of center study would be necessary to determine whether
1.5 – this may be too low to capture the times when our changes in triage destination have a negative impact on
department was under the most stress. The cut-off was patient outcomes. As triage is the first point of contact
based on local expert consensus rather than literature- with ED staff, this interaction influences the patient’s en-
based, as there is no accepted threshold for ED crowding tire stay in the department and should be an important
using ED occupancy in the literature. It is possible that a area for future ED crowding research.
higher ED occupancy level would show a larger differ-
ence between the groups. Also, ED occupancy was cal-
culated at the time of triage, reflecting only occupancy Conclusions
at that one time. Change in occupancy level throughout In this pilot study, we found that during crowded condi-
the patients’ stay in the ED may also have affected the tions, high acuity patients presenting with chest pain or
investigations ordered and potentially the rate of return shortness of breath had a higher rate of triage to the
to the ED. Due to the retrospective nature of the study non-monitored area of the ED, longer times to physician
design, we were unable to determine if CTAS scores initial assessment, and an associated lower rate of inves-
were appropriately assigned for the patients in the study. tigations. Despite these findings, with our small sample
Previous literature suggests that assignment of CTAS size we could not detect a difference in rates of unsched-
score has a good inter-rater reliability [24,25]. However, uled returns to our institution. Future research should
it is possible that ED crowding influenced assignment of be directed at examining whether these changes in triage
CTAS score. This study was based on the assumption destination during crowded conditions lead to worse pa-
that patients with the same chief complaint and the tient outcomes.
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Abbreviations Department Triage and Acuity Implementation Guidelines. CJEM 1999,

CTAS: Canadian Triage and Acuity Scale; ED: Emergency Department. 1(3 suppl):S2–S28.
17. McCarthy ML, Aronsky D, Jones ID, Miner JR, Band RA, Baren JM, Desmond JS,
Competing interests Baumlin KM, Ding R, Shesser R: The emergency department occupancy rate:
The authors declare that they have no competing interests. a simple measure of emergency department crowding? Ann Emerg Med
2008, 51(1):15–24.
18. Moskop JC, Sklar DP, Geiderman JM, Schears RM, Bookman KJ: Emergency
Authors’ contributions department crowding, part 1–concept, causes, and moral consequences.
EO conceived of the study, gathered data, and drafted the manuscript. MG Ann Emerg Med 2009, 53(5):605–611.
revised the manuscript. CW gathered data and revised the manuscript. LC 19. Ospina MB, Bond K, Schull M, Innes G, Blitz S, Rowe BH: Key indicators of
supervised development of the study design and coordination and revised overcrowding in Canadian emergency departments: a Delphi study.
the manuscript. All authors read and approved the final manuscript. CJEM 2007, 9(5):339–346.
20. Calder L, Tierney S, Jiang Y, Gagné A, Gee A, Hobden E, Vaillancourt C, Perry J,
Acknowledgements Stiell I, Forster A: Patient safety analysis of the ED care of patients with heart
The study was supported by a research grant from the Department of failure and COPD exacerbations: a multicenter prospective cohort study.
Emergency Medicine, University of Ottawa. We thank Rina Marcantonio for Am J Emerg Med 2014, 32(1):29–35.
identification of health records, Angela Marcantonio for help with 21. Asplin BR, Magid DJ, Rhodes KV, Solberg LI, Lurie N, Camargo CA: A
submission to the research ethics board and grant application, Cheryl conceptual model of emergency department crowding. Ann Emerg Med
Geymonat for help in obtaining data, Guy Hebert and Adam Cwinn for their 2003, 42(2):173–180.
help in determining an ED occupancy cut-off, Tinghua Zhang for statistical 22. Hu K-W, Lu Y-H, Lin H-J, Guo H-R, Foo N-P: Unscheduled return visits with
analysis, and Ben Kenney for technical support with the database. and without admission post emergency department discharge. J Emerg
Med 2012, 43(6):1110–1118.
Received: 4 November 2013 Accepted: 4 April 2014 23. Guttmann A, Schull MJ, Vermeulen MJ, Stukel TA: Association between
Published: 28 April 2014 waiting times and short term mortality and hospital admission after
departure from emergency department: population based cohort study
from Ontario. Canada. BMJ 2011, 342:d2983.
References 24. Fernandes CMB, Mcleod S, Krause J, Shah A, Jewell J, Smith B, Rollins L:
1. Dickinson G: Emergency department overcrowding. CMAJ 1989, Reliability of the Canadian Triage and Acuity Scale: interrater and
140(3):270–271. intrarater agreement from a community and an academic emergency
2. Yoon P, Steiner I, Reinhardt G: Analysis of factors influencing length of department. CJEM 2013, 15(4):227–232.
stay in the emergency department. CJEM 2003, 5(3):155–161. 25. Manos D, Petrie D, Beveridge R: Inter-observer agreement using the
3. FitzGerald G, Jelinek GA, Scott D, Gerdtz MF: Emergency department triage Canadian Emergency Department Triage and Acuity Scale. CJEM 2002,
revisited. Emerg Med J 2010, 27(2):86–92. 4(1):16–22.
4. Croskerry P: The importance of cognitive errors in diagnosis and
strategies to minimize them. Acad Med 2003, 78(8):775–780.
doi:10.1186/1865-1380-7-16
5. Richardson DB: Increase in patient mortality at 10 days associated with
Cite this article as: O’Connor et al.: Evaluating the effect of emergency
emergency department overcrowding. Med J Aust 2006, 184(5):213–216. department crowding on triage destination. International Journal of
6. Hong KJ, Do SS, Song KJ, Cha WC, Cho JS: Association between ED Emergency Medicine 2014 7:16.
crowding and delay in resuscitation effort. Am J Emerg Med 2013,
31(3):509–515.
7. Pines JM, Pollack CV, Diercks DB, Chang AM, Shofer FS, Hollander JE: The
association between emergency department crowding and adverse
cardiovascular outcomes in patients with chest pain. Acad Emerg Med
2009, 16(7):617–625.
8. Pines JM, Hollander JE, Localio AR, Metlay JP: The association between
emergency department crowding and hospital performance on
antibiotic timing for pneumonia and percutaneous intervention for
myocardial infarction. Acad Emerg Med 2006, 13(8):873–878.
9. Fee C, Weber EJ, Maak CA, Bacchetti P: Effect of emergency department
crowding on time to antibiotics in patients admitted with
community-acquired pneumonia. Ann Emerg Med 2007, 50(5):501–509.
10. Ackroyd-Stolarz S, Read Guernsey J, Mackinnon NJ, Kovacs G: The
association between a prolonged stay in the emergency department
and adverse events in older patients admitted to hospital: a
retrospective cohort study. BMJ Qual Saf 2011, 20(7):564–569.
11. Hwang U, Richardson LD, Sonuyi TO, Morrison RS: The effect of emergency
department crowding on the management of pain in older adults with
hip fracture. J Am Geriatr Soc 2006, 54(2):270–275.
12. Pines JM, Hollander JE: Emergency department crowding is associated Submit your manuscript to a
with poor care for patients with severe pain. Ann Emerg Med 2008,
51(1):1–5. journal and benefit from:
13. Pines JM, Iyer S, Disbot M, Hollander JE, Shofer FS, Datner EM: The effect of
emergency department crowding on patient satisfaction for admitted 7 Convenient online submission
patients. Acad Emerg Med 2008, 15(9):825–831. 7 Rigorous peer review
14. Bullard M, Unger B, Spence J, Grafstein E: Revisions to the Canadian 7 Immediate publication on acceptance
Emergency Department Triage and Acuity Scale (CTAS) adult guidelines. 7 Open access: articles freely available online
CJEM 2008, 10(2):136–142.
7 High visibility within the field
15. Beveridge R, Ducharme J, Janes L, Beaulieu S, Walter S: Reliability of the
Canadian emergency department triage and acuity scale: interrater 7 Retaining the copyright to your article
agreement. Ann Emerg Med 1999, 34(2):155–159.
16. Beveridge R, Clarke B, Janes L, Savage N, Thompson J, Dodd G, Murray M,
Submit your next manuscript at 7 springeropen.com
Nijssen-Jordan C, Warren D, Vadeboncoeur A: Canadian Emergency