Association between ED crowding and delay in resuscitation effort

Published:November 19, 2012DOI:


      Study objective

      Few investigations have been performed that address why emergency department (ED) crowding is associated with an increase in hospital mortality for emergency patients. The purpose of this study was to evaluate whether ED crowding is associated with delayed resuscitation efforts (DREs) that resulted in hospital mortality.


      This is a retrospective observational study performed at a single urban tertiary ED. All adult patients who entered the resuscitation room and underwent resuscitative procedures from October 2008 to May 2010 were enrolled in the study. Demographic data were collected from a designed resuscitation room registry. The ED electronic log data were used for calculating the crowding status. A crowded day was defined as a daily number of patients greater than 93, which was a cut-off derived from a sensitivity analysis. The primary outcome was a DRE, which occurred when a patient was located in the hallway or waiting room, then entered the resuscitation room, and received resuscitative procedures after the patient had clinically deteriorated. A secondary outcome was hospital mortality. Matched samples were selected using propensity scores to consider the clinical parameters and emergency severity index when the patients received triage immediately after registration. A logistic regression analysis was modeled to estimate the odds ratios (ORs) with 95% confidence intervals (CIs) on the DRE.


      A total of 1296 patients underwent resuscitative procedures in the resuscitation room. Of these, 226 (17.4%) were classified as the DRE group. A final 396 cases (30.6%) were matched and analyzed between DRE and non-DRE using the propensity score. The incidence of DRE was significantly higher on crowded days (OR, 2.00; 95% CI, 1.28-3.15). Mortality during the ED stay or during the total hospital stay was significantly higher in the DRE group (OR, 3.39; 95% CI, 1.22-9.45 and OR, 3.96; 95% CI, 2.28-6.88, respectively) compared with the non-DRE group.


      Delays in resuscitation efforts occurred more frequently on crowded days and were associated with higher in-hospital mortality.
      To read this article in full you will need to make a payment
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • American College of Emergency Physicians
        Policy statements: crowding.
        Ann Emerg Med. 2006; 47: 585
        • Derlet R.W.
        • Richards J.R.
        Emergency department overcrowding in Florida, New York, and Texas.
        South Med J. 2002; 95: 846-849
        • Sprivulis P.C.
        • Da Silva J.A.
        • Jacobs I.G.
        • et al.
        The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments.
        Med J Aust. 2006; 184: 208-212
        • Richardson D.B.
        Increase in patient mortality at 10 days associated with emergency department overcrowding.
        Med J Aust. 2006; 184: 213-216
        • Miró O.
        • Antonio M.T.
        • Jiménez S.
        • et al.
        Decreased health care quality associated with emergency department overcrowding.
        Eur J Emerg Med. 1999; 6: 105-107
        • Sikka R.
        • Mehta S.
        • Kaucky C.
        • et al.
        ED crowding is associated with an increased time to pneumonia treatment.
        Am J Emerg Med. 2010; 28: 809-812
        • Pines J.M.
        • Shofer F.S.
        • Isserman J.A.
        • et al.
        The effect of emergency department crowding on analgesia in patients with back pain in two hospitals.
        Acad Emerg Med. 2010; 17: 276-283
        • Bernhard M.
        • Becker T.K.
        • Nowe T.
        • et al.
        Introduction of a treatment algorithm can improve the early management of emergency patients in the resuscitation room.
        Resuscitation. 2007; 73: 362-373
        • Claudet I.
        • Bounes V.
        • Fédérici S.
        • et al.
        Epidemiology of admissions in a pediatric resuscitation room.
        Pediatr Emerg Care. 2009; 25: 312-316
        • Cattermole G.N.
        • Mak S.K.
        • Liow C.H.
        • et al.
        Derivation of a prognostic score for identifying critically ill patients in an emergency department resuscitation room.
        Resuscitation. 2009; 80: 1000-1005
        • Pines J.M.
        • Hollander J.E.
        • Localio A.R.
        • et al.
        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: 873-878
        • Pines J.M.
        • Hollander J.E.
        Emergency department crowding is associated with poor pain care for patients with severe pain.
        Ann Emerg Med. 2008; 51: 1-5
        • Hwang U.
        • Richardson L.D.
        • Sonuyi T.O.
        • et al.
        The effect of emergency department crowding on the management of pain in older adults with hip fracture.
        J Am Geriatr Soc. 2006; 54: 270-275
        • Schull M.J.
        • Morrison L.J.
        • Vermeulen M.
        • et al.
        Emergency department overcrowding and ambulance transport delays for patients with chest pain.
        CMAJ. 2003; 168: 277-283
        • Schull M.J.
        • Vermeulen M.
        • Slaughter G.
        • et al.
        Emergency department crowding and thrombolysis delays in acute myocardial infarction.
        Ann Emerg Med. 2004; 44: 577-585
        • Harris B.
        • Bai J.C.
        • Kulstad E.B.
        Crowding does not adversely affect time to percutaneous coronary intervention for acute myocardial infarction in a community emergency department.
        Ann Emerg Med. 2012 Jan; 59: 13-17
        • Austin P.C.
        Propensity-score matching in the cardiovascular surgery literature from 2004 to 2006: a systematic review and suggestions for improvement.
        J Thorac Cardiovasc Surg. 2007; 134: 1128-1135
        • Austin P.C.
        Primer on statistical interpretation or methods report card on propensity-score matching in the cardiology literature from 2004 to 2006: a systematic review.
        Circ Cardiovasc Qual Outcomes. 2008; 1: 62-67
        • Kim S.I.
        • Kim C.J.
        • Kim Y.J.
        • et al.
        Antiviral prophylaxis versus preemptive therapy to prevent cytomegalovirus infection and related death in liver transplantation: a retrospective study with propensity score matching.
        Transplant Proc. 2012; 44: 787-790
        • Loucks E.B.
        • Buka S.L.
        • Rogers M.L.
        • et al.
        Education and coronary heart disease risk associations may be affected by early-life common prior causes: a propensity matching analysis.
        Ann Epidemiol. 2012; 22: 221-232