The Relationship Between Overcrowding Conditions and Service Quality in The Emergency Department
Article Sidebar
Main Article Content
Abstract
Background: Overcrowding in the Emergency Department (ED) is a significant issue worldwide. ED overcrowding is associated with numerous negative consequences; it can also affect the efficiency and quality of medical care provided to patients. Patients with conditions requiring immediate attention may experience delays in receiving care, which can negatively impact treatment outcomes.
Objectives: To analyze the relationship between overcrowding conditions and service quality in the Emergency Department
Methods: This cross-sectional study was conducted in an ED in May 2026 involving 124 respondents selected through accidental sampling. Participants included stable adult patients or family caregivers aged ≥ 17 years; patients requiring immediate resuscitation were excluded. Overcrowding was evaluated using the 7-item National Emergency Department Overcrowding Scale (NEDOCS) across six categories. Service quality was assessed using an adapted 22-item SERVQUAL questionnaire (r > 0.361, α = 0.855) categorized into Good, Fair, and Poor. Data were evaluated using descriptive statistics and the Spearman Rank correlation test.
Results: Most respondents were aged 46–55 years (n = 44, 35.5%) and female (n = 70, 56.5%). ED overcrowding was predominantly categorized as Crowded/Overcrowded (n = 40, 32.3%), followed by Severely Overcrowded (n = 36, 29.0%), Dangerously Overcrowded (n = 24, 19.4%), Very Busy (n = 22, 17.7%), and Busy (n = 2, 1.6%). Service quality was rated Good by 67 respondents (54.0%), Fair by 51 (41.1%), and Poor by 6 (4.8%). Bivariate analysis demonstrated a statistically significant inverse correlation between ED overcrowding conditions and service quality.
Conclusion: Higher ED overcrowding is inversely associated with lower service quality ratings. Future research should employ longitudinal multi-center designs and incorporate objective clinical throughput metrics.
Downloads
Article Details
Section
How to Cite
References
Aalam, A. A. (2024). Patient demographics and emergency department utilization trends in acute healthcare settings. Journal of Emergency Nursing, 50(2), 145–154. https://doi.org/10.1016/j.jen.2023.11.004
Afonso, R., Mestre, M., & Ribeiro, C. (2021). Impact of emergency department overcrowding on delay in clinical interventions and patient satisfaction: A prospective study. International Journal of Emergency Medicine, 14(1), Article 58. https://doi.org/10.1186/s12245-021-00382-7
Al-Neyadi, H. S., Abdallah, S., & Malik, M. (2018). Measuring patient’s satisfaction of healthcare services in the UAE hospitals: Using SERVQUAL quantification. International Journal of Healthcare Management, 11(4), 275–281. https://doi.org/10.1080/20479700.2016.1266804
Altun, M., Kaya, E., & Yılmaz, A. (2025). Overcrowding in emergency departments: A scoping literature review. Anatolian Journal of Emergency Medicine, 8(2), 94–100. https://doi.org/10.54996/anatolianjem.1684632
Atohm, M., Al-Ghamdi, S., & Al-Zahrani, B. (2023). The association between emergency department overcrowding and delay in treatment: A systematic review. International Journal of Environmental Research and Public Health, 20(3), Article 1887. https://doi.org/10.3390/ijerph20031887
Carter, E. J., Pouch, S. M., & Larson, E. L. (2016). The relationship between emergency department crowding and patient outcomes: A systematic review. Journal of Nursing Scholarship, 46(2), 106–115. https://doi.org/10.1111/jnu.12055
Chang, A. M., Lin, A., Fu, R., & Lowe, R. A. (2022). Emergency department crowding and quality of care: A systematic review of operational and clinical outcomes. Academic Emergency Medicine, 29(5), 614–625. https://doi.org/10.1111/acem.14442
Hitti, E., Hadid, D., Melki, J., & Tamim, H. (2020). Validation of the National Emergency Department Overcrowding Score (NEDOCS) in an international setting: Measuring crowding in a tertiary care center. BMC Emergency Medicine, 20(1), Article 45. https://doi.org/10.1186/s12873-020-00340-9
Morley, C., Unwin, M., Peterson, G. M., Stankovich, J., & Kinsman, L. (2018). Emergency department crowding: A systematic review of causes, consequences and solutions. PLOS ONE, 13(8), Article e0203316. https://doi.org/10.1371/journal.pone.0203316
Mostafa, R., & El-Atawi, K. (2024). Strategies to measure and improve emergency department performance: A review. Cureus, 16(1), Article e52341. https://doi.org/10.7759/cureus.52341
Parasuraman, A., Zeithaml, V. A., & Berry, L. L. (1988). SERVQUAL: A multiple-item scale for measuring consumer perceptions of service quality. Journal of Retailing, 64(1), 12–40.
Pines, J. M., Griffey, R. T., & Uscher-Pines, L. (2017). Emergency department crowding and the quality of emergency care. Emergency Medicine Clinics of North America, 35(3), 517–528. https://doi.org/10.1016/j.emc.2017.03.003
Rasouli, H. R., Esfahani, M., Vahdati, S. S., & Farahmand, S. (2019). Patients’ satisfaction in emergency departments: A systematic review. Emergency, 7(1), Article e36. https://doi.org/10.22037/emergency.v7i1.24647
Salway, R. J., Valenzuela, R., Shoenberger, J. M., Mallon, W. K., & Vicellio, A. (2020). Emergency department crowding: Causes, consequences, and solutions. Emergency Medicine Clinics of North America, 38(2), 277–292. https://doi.org/10.1016/j.emc.2020.01.002
Savioli, F., Alfieri, A., Zanza, C., Longhitano, Y., Racca, F., Desideri, G., & Piccioni, A. (2022). Quality of care and patient satisfaction in the emergency department: A review of the Donabedian model application. Emergency Care Journal, 18(2), Article 10562. https://doi.org/10.4081/ecj.2022.10562
Szekendi, M. K., Williams, M. V., Carrier, D., & Cerese, J. (2015). The input-throughput-output model of emergency department crowding: A multi-center evaluation of throughput strategies. Journal of Healthcare Management, 60(1), 27–41. https://doi.org/10.1097/00115514-201501000-00007
Tekwani, K. L., Watts, H. F., Sweis, R. T., & Rzechula, K. H. (2015). A comparison of the NEDOCS score to clinician and nurse perception of emergency department crowding. International Journal of Emergency Medicine, 8(1), Article 20. https://doi.org/10.1186/s12245-015-0068-1
Tsai, C. L., Liang, C. C., & Teng, C. C. (2021). The relationship between hospital overcrowding, wait times, and emergency service quality: An empirical study. Healthcare, 9(11), Article 1422. https://doi.org/10.3390/healthcare9111422
World Health Organization. (2021). Emergency care systems for universal health coverage: Ensuring timely care and service quality. World Health Organization. https://www.who.int/publications/i/item/9789240028784
Yarmohammadian, M. H., Rezaei, F., Haghshenas, A., & Tavakoli, N. (2017). Overcrowding in emergency departments: A review of strategies to decrease response time and patient waiting time. Journal of Research in Medical Sciences, 22(1), Article 23. https://doi.org/10.4103/1735-1995.200277
Zeinali, N., Bastani, P., & Delavari, S. (2020). Factors affecting the quality of emergency department services: A qualitative study using the SERVQUAL model. Journal of Health Management and Informatics, 7(3), 173–181. https://doi.org/10.30476/jhmi.2020.87114.1068