JMIR Publications

ABSTRACT

Background:

Emergency department (ED) overcrowding is a persistent global health issue associated with adverse patient outcomes, diminished staff performance, and compromised health-system efficiency. Despite widespread recognition of the problem, there is no universally accepted approach to monitoring ED overcrowding. The use of disparate, non-standardised indicators hampers cross-country comparison and the development of effective policies. A comprehensive synthesis of indicators currently employed is essential to guide the adoption of robust, evidence-based metrics across diverse healthcare settings.

Objective:

This scoping review aims to identify, consolidate, and categorise indicators that have been used internationally to assess ED overcrowding and to highlight gaps in their utilisation.

Methods:

A comprehensive scoping review was conducted from October to November 2023, adhering to the PRISMA-ScR framework to ensure methodological rigor and transparency. Four electronic databases were used. Studies from PubMed, Scopus, Emerald Insight, and Google Scholar were systematically searched using predefined eligibility criteria to capture relevant literature. The level one and two screening processes, independently undertaken by nine researchers to minimize selection bias and enhance reliability and findings were verified and discrepancies resolved through researcher consensus to ensure accuracy. Finally, a third independent reviewer conducted full-text review, synthesis, and descriptive analysis of the included articles. Following data extraction, the identified indicators were systematically categorized according to their respective components: input, throughput, and output. Descriptive analyses were then employed to consolidate these indicators and to establish their relative importance. They were ranked based on frequency of reporting across diverse countries and healthcare settings.

Results:

Out of 1,347 articles screened, 117 articles were included in the study. A total of 307 indicators were retrieved and then consolidated into 26 distinct indicators. The majority of indicators were classified within the throughput domain (n = 209; 68%), followed by the output domain (n = 62; 20%) and the input domain (n = 36; 12%). The most common throughput indicator which was frequently reported, was ED length of stay (LOS), cited 87 times, followed by left without being seen and waiting time, each reported 30 times. LOS consistently emerged as a primary marker of systemic bottlenecks and operational inefficiencies across healthcare systems.

Conclusions:

This review indicates that throughput measures, particularly LOS, dominate current approaches to assessing ED overcrowding, whereas input and output indicators remain comparatively underrepresented. By consolidating 26 distinct indicators from 117 studies, this study provides a comprehensive evidence base to support the standardisation of metrics for monitoring ED overcrowding internationally. These findings offer practical guidance for policymakers and healthcare leaders seeking to refine performance indicators, enhance benchmarking, and evaluate interventions aimed at improving patient flow. Further research should prioritise validation of underutilised indicators and the development of composite measures that better capture the complexity of ED crowding across diverse healthcare settings.