BACKGROUND: In patients with chest pain who arrive at the emergency department (ED) by ambulance, venous access is frequently established prehospital, and could be utilized to sample blood. Prehospital blood sampling may save time in the diagnostic process. In this study, the association of prehospital blood draw with blood sample arrival times, troponin turnaround times, and ED length of stay (LOS), number of blood sample mix-ups and blood sample quality were assessed. METHODS: The study was conducted from October 1, 2019 to February 29, 2020. In patients who were transported to the ED with acute chest pain with low suspicion for acute coronary syndrome (ACS), outcomes were compared between cases, in whom prehospital blood draw was performed, and controls, in whom blood was drawn at the ED. Regression analyses were used to assess the association of prehospital blood draw with the time intervals. RESULTS: Prehospital blood draw was performed in 100 patients. In 406 patients, blood draw was performed at the ED. Prehospital blood draw was independently associated with shorter blood sample arrival times, shorter troponin turnaround times and decreased LOS (P<0.001). No differences in the number of blood sample mix-ups and quality were observed (P>0.05). CONCLUSION: For patients with acute chest pain with low suspicion for ACS, prehospital blood sampling is associated with shorter time intervals, while there were no significant differences between the two groups in the validity of the blood samples. @en

Background: During a 6-year period, several process changes were introduced at the emergency department (ED) to decrease crowding, such as the implementation of a general practitioner cooperative (GPC) and additional medical staff during peak hours. In this study, we assessed the effects of these process changes on three crowding measures: patients’ length of stay (LOS), the modified National ED OverCrowding Score (mNEDOCS), and exit block while taking into account changing external circumstances, such as the COVID-19 pandemic and centralization of acute care. Methods: We determined time points of the various interventions and external circumstances and built an interrupted time-series (ITS) model per outcome measure. We analyzed changes in level and trend before and after the selected time points using ARIMA modeling, to account for autocorrelation in the outcome measures. Results: Longer patients’ ED LOS was associated with more inpatient admissions and more urgent patients. The mNEDOCS decreased with the integration of the GPC and the expansion of the ED to 34 beds and increased with the closure of a neighboring ED and ICU. More exit blocks occurred when more patients with shortness of breath and more patients > 70 years of age presented to the ED. During the severe influenza wave of 2018–2019, patients’ ED LOS and the number of exit blocks increased. Conclusions: In the ongoing battle against ED crowding, it is pivotal to understand the effect of interventions, corrected for changing circumstances and patient and visit characteristics. In our ED, interventions which were associated with decreased crowding measures included the expansion of the ED with more beds and the integration of the GPC on the ED.@en

Background: During a 6-year period, several process changes were introduced at the emergency department (ED) to decrease crowding, such as the implementation of a general practitioner cooperative (GPC) and additional medical staff during peak hours. In this study, we assessed the effects of these process changes on three crowding measures: patients’ length of stay (LOS), the modified National ED OverCrowding Score (mNEDOCS), and exit block while taking into account changing external circumstances, such as the COVID-19 pandemic and centralization of acute care. Methods: We determined time points of the various interventions and external circumstances and built an interrupted time-series (ITS) model per outcome measure. We analyzed changes in level and trend before and after the selected time points using ARIMA modeling, to account for autocorrelation in the outcome measures. Results: Longer patients’ ED LOS was associated with more inpatient admissions and more urgent patients. The mNEDOCS decreased with the integration of the GPC and the expansion of the ED to 34 beds and increased with the closure of a neighboring ED and ICU. More exit blocks occurred when more patients with shortness of breath and more patients > 70 years of age presented to the ED. During the severe influenza wave of 2018–2019, patients’ ED LOS and the number of exit blocks increased. Conclusions: In the ongoing battle against ED crowding, it is pivotal to understand the effect of interventions, corrected for changing circumstances and patient and visit characteristics. In our ED, interventions which were associated with decreased crowding measures included the expansion of the ED with more beds and the integration of the GPC on the ED.@en

Background: During a 6-year period, several process changes were introduced at the emergency department (ED) to decrease crowding, such as the implementation of a general practitioner cooperative (GPC) and additional medical staff during peak hours. In this study, we assessed the effects of these process changes on three crowding measures: patients’ length of stay (LOS), the modified National ED OverCrowding Score (mNEDOCS), and exit block while taking into account changing external circumstances, such as the COVID-19 pandemic and centralization of acute care. Methods: We determined time points of the various interventions and external circumstances and built an interrupted time-series (ITS) model per outcome measure. We analyzed changes in level and trend before and after the selected time points using ARIMA modeling, to account for autocorrelation in the outcome measures. Results: Longer patients’ ED LOS was associated with more inpatient admissions and more urgent patients. The mNEDOCS decreased with the integration of the GPC and the expansion of the ED to 34 beds and increased with the closure of a neighboring ED and ICU. More exit blocks occurred when more patients with shortness of breath and more patients > 70 years of age presented to the ED. During the severe influenza wave of 2018–2019, patients’ ED LOS and the number of exit blocks increased. Conclusions: In the ongoing battle against ED crowding, it is pivotal to understand the effect of interventions, corrected for changing circumstances and patient and visit characteristics. In our ED, interventions which were associated with decreased crowding measures included the expansion of the ED with more beds and the integration of the GPC on the ED.@en

Background: During a 6-year period, several process changes were introduced at the emergency department (ED) to decrease crowding, such as the implementation of a general practitioner cooperative (GPC) and additional medical staff during peak hours. In this study, we assessed the effects of these process changes on three crowding measures: patients’ length of stay (LOS), the modified National ED OverCrowding Score (mNEDOCS), and exit block while taking into account changing external circumstances, such as the COVID-19 pandemic and centralization of acute care. Methods: We determined time points of the various interventions and external circumstances and built an interrupted time-series (ITS) model per outcome measure. We analyzed changes in level and trend before and after the selected time points using ARIMA modeling, to account for autocorrelation in the outcome measures. Results: Longer patients’ ED LOS was associated with more inpatient admissions and more urgent patients. The mNEDOCS decreased with the integration of the GPC and the expansion of the ED to 34 beds and increased with the closure of a neighboring ED and ICU. More exit blocks occurred when more patients with shortness of breath and more patients > 70 years of age presented to the ED. During the severe influenza wave of 2018–2019, patients’ ED LOS and the number of exit blocks increased. Conclusions: In the ongoing battle against ED crowding, it is pivotal to understand the effect of interventions, corrected for changing circumstances and patient and visit characteristics. In our ED, interventions which were associated with decreased crowding measures included the expansion of the ED with more beds and the integration of the GPC on the ED.@en

Background: During a 6-year period, several process changes were introduced at the emergency department (ED) to decrease crowding, such as the implementation of a general practitioner cooperative (GPC) and additional medical staff during peak hours. In this study, we assessed the effects of these process changes on three crowding measures: patients’ length of stay (LOS), the modified National ED OverCrowding Score (mNEDOCS), and exit block while taking into account changing external circumstances, such as the COVID-19 pandemic and centralization of acute care. Methods: We determined time points of the various interventions and external circumstances and built an interrupted time-series (ITS) model per outcome measure. We analyzed changes in level and trend before and after the selected time points using ARIMA modeling, to account for autocorrelation in the outcome measures. Results: Longer patients’ ED LOS was associated with more inpatient admissions and more urgent patients. The mNEDOCS decreased with the integration of the GPC and the expansion of the ED to 34 beds and increased with the closure of a neighboring ED and ICU. More exit blocks occurred when more patients with shortness of breath and more patients > 70 years of age presented to the ED. During the severe influenza wave of 2018–2019, patients’ ED LOS and the number of exit blocks increased. Conclusions: In the ongoing battle against ED crowding, it is pivotal to understand the effect of interventions, corrected for changing circumstances and patient and visit characteristics. In our ED, interventions which were associated with decreased crowding measures included the expansion of the ED with more beds and the integration of the GPC on the ED.@en

Introduction: Previous studies indicate that crowding scales may not perform well in low-volume emergency departments (EDs). In this study, face-validity of the Modified National ED OverCrowding Score (mNEDOCS) was assessed in a high-volume ED as well as in a low-volume ED. Methods: A prospective observational cohort study was performed in the Netherlands. The correlation of the mNEDOCS with ED staff perceptions of crowding were assessed, using weighted Kappa (κ) and Pearson correlation. Subsequently, ED process measures (elapsed target times to triage, elapsed target times to treatment and patients’ LOS) were described under different levels of ED crowding. Results: Correlation between the categorized crowding scores was low (weighted κ 0.34 resp. 0.26). However, good correlations of 0.73 and 0.82 were found between the uncategorized mNEDOCS and ED staff's perception of crowding. Percentages of patients with elapsed target times to treatment increased simultaneously with increasingly busy periods when measured with mNEDOCS. Conclusions: The uncategorized mNEDOCS correlates well with perceived crowding, even at a low-volume ED. Determining a cut-off level at which a specific ED can be identified as crowded is important, because the predefined mNEDOCS categories may not be optimal for all EDs.@en

Introduction: Previous studies indicate that crowding scales may not perform well in low-volume emergency departments (EDs). In this study, face-validity of the Modified National ED OverCrowding Score (mNEDOCS) was assessed in a high-volume ED as well as in a low-volume ED. Methods: A prospective observational cohort study was performed in the Netherlands. The correlation of the mNEDOCS with ED staff perceptions of crowding were assessed, using weighted Kappa (κ) and Pearson correlation. Subsequently, ED process measures (elapsed target times to triage, elapsed target times to treatment and patients’ LOS) were described under different levels of ED crowding. Results: Correlation between the categorized crowding scores was low (weighted κ 0.34 resp. 0.26). However, good correlations of 0.73 and 0.82 were found between the uncategorized mNEDOCS and ED staff's perception of crowding. Percentages of patients with elapsed target times to treatment increased simultaneously with increasingly busy periods when measured with mNEDOCS. Conclusions: The uncategorized mNEDOCS correlates well with perceived crowding, even at a low-volume ED. Determining a cut-off level at which a specific ED can be identified as crowded is important, because the predefined mNEDOCS categories may not be optimal for all EDs.@en

Background: In The Netherlands, the state of emergency department (ED) crowding is unknown. Anecdotal evidence suggests that current ED patients experience a longer length of stay (LOS) compared to some years ago, which is indicative of ED crowding. However, no multicenter studies have been performed to quantify LOS and assess crowding at Dutch EDs. We performed this study to describe the current state of emergency departments in The Netherlands regarding patients' length of stay and ED nurse managers' experiences of crowding. Methods: A survey was sent to all 94 ED nurse managers in The Netherlands with questions regarding the type of facility, annual ED census, and patients' LOS. Additional questions included whether crowding was ever a problem at the particular ED, how often it occurred, which time periods had the worst episodes of crowding, and what measures the particular ED had undertaken to improve patient flow. Results: Surveys were collected from 63 EDs (67%). Mean annual ED visits were 24,936 (SD ± 9,840); mean LOS for discharged patients was 119 (SD ± 40) min and mean LOS for admitted patients 146 (SD ± 49) min. Consultation delays, laboratory and radiology delays, and hospital bed shortages for patients needing admission were the most cited reasons for crowding. Admitted patients had a longer LOS because of delays in obtaining inpatient beds. Thirty-nine of 57 respondents (68%) reported that crowding occurred several times a week or even daily, mostly between 12:00 and 20:00. Measures taken by hospitals to manage crowding included placing patients in hallways and using fasttrack with treatment of patients by trained nurse practitioners. Conclusions: Despite a relatively short LOS, frequent crowding appears to be a nationwide problem according to Dutch ED nurse managers, with 68% of them reporting that crowding occurred several times a week or even daily. Consultations delays, laboratory and radiology delays, and hospital bed shortage for patients needing admission were believed to be the most important factors contributing to ED crowding.@en

Background: In The Netherlands, the state of emergency department (ED) crowding is unknown. Anecdotal evidence suggests that current ED patients experience a longer length of stay (LOS) compared to some years ago, which is indicative of ED crowding. However, no multicenter studies have been performed to quantify LOS and assess crowding at Dutch EDs. We performed this study to describe the current state of emergency departments in The Netherlands regarding patients' length of stay and ED nurse managers' experiences of crowding. Methods: A survey was sent to all 94 ED nurse managers in The Netherlands with questions regarding the type of facility, annual ED census, and patients' LOS. Additional questions included whether crowding was ever a problem at the particular ED, how often it occurred, which time periods had the worst episodes of crowding, and what measures the particular ED had undertaken to improve patient flow. Results: Surveys were collected from 63 EDs (67%). Mean annual ED visits were 24,936 (SD ± 9,840); mean LOS for discharged patients was 119 (SD ± 40) min and mean LOS for admitted patients 146 (SD ± 49) min. Consultation delays, laboratory and radiology delays, and hospital bed shortages for patients needing admission were the most cited reasons for crowding. Admitted patients had a longer LOS because of delays in obtaining inpatient beds. Thirty-nine of 57 respondents (68%) reported that crowding occurred several times a week or even daily, mostly between 12:00 and 20:00. Measures taken by hospitals to manage crowding included placing patients in hallways and using fasttrack with treatment of patients by trained nurse practitioners. Conclusions: Despite a relatively short LOS, frequent crowding appears to be a nationwide problem according to Dutch ED nurse managers, with 68% of them reporting that crowding occurred several times a week or even daily. Consultations delays, laboratory and radiology delays, and hospital bed shortage for patients needing admission were believed to be the most important factors contributing to ED crowding.@en

Background: Nearly all Dutch citizens have a general practitioner (GP), acting as a gatekeeper to secondary care. Some patients bypass the GP and present to the emergency department (ED). To make best use of existing emergency care, Dutch health policy makers and insurance companies have proposed the integration of EDs and GP cooperatives (GPCs) into one facility. In this study, we examined ED use and assessed the characteristics of self-referrals and non-self-referrals, their need for hospital emergency care and self-referrals' motives for presenting at the ED. Methods: A descriptive cohort study was conducted in a Dutch level 1 trauma centre. Differences in patient characteristics, time of presentation and need for hospital emergency care were analysed using χ2 tests and t tests. A patient was considered to need hospital emergency care when he/she was admitted to the hospital, had an extremity fracture and/or when diagnostic tests were performed. Main determinants of self-referral were identified via logistic regression. Results: Of the 5,003 consecutive ED patients registering within the 5-week study period, 3,028 (60.5%) were self-referrals. Thirty-nine percent of the self-referrals had urgent acuity levels, as opposed to 65% of the non-self-referrals. Self-referrals more often suffered from injuries (49 vs. 20%). One third of the self-referrals presented during office hours. Of all self-referrals, 51% needed hospital emergency care. Younger age; non-urgent acuity level; chest pain, ear, nose or throat problems; and injuries were independent predictors for self-referral. Most cited motives for self-referring were ‘accessibility and convenience’ and perceived ‘medical necessity’. Conclusions: A substantial part of the self-referrals needed hospital emergency care. The 49% self-referrals who were eligible for GP care presented during out-of-hours as well as during office hours. This calls for an integrative approach to this health care problem.@en

Background: Nearly all Dutch citizens have a general practitioner (GP), acting as a gatekeeper to secondary care. Some patients bypass the GP and present to the emergency department (ED). To make best use of existing emergency care, Dutch health policy makers and insurance companies have proposed the integration of EDs and GP cooperatives (GPCs) into one facility. In this study, we examined ED use and assessed the characteristics of self-referrals and non-self-referrals, their need for hospital emergency care and self-referrals' motives for presenting at the ED. Methods: A descriptive cohort study was conducted in a Dutch level 1 trauma centre. Differences in patient characteristics, time of presentation and need for hospital emergency care were analysed using χ2 tests and t tests. A patient was considered to need hospital emergency care when he/she was admitted to the hospital, had an extremity fracture and/or when diagnostic tests were performed. Main determinants of self-referral were identified via logistic regression. Results: Of the 5,003 consecutive ED patients registering within the 5-week study period, 3,028 (60.5%) were self-referrals. Thirty-nine percent of the self-referrals had urgent acuity levels, as opposed to 65% of the non-self-referrals. Self-referrals more often suffered from injuries (49 vs. 20%). One third of the self-referrals presented during office hours. Of all self-referrals, 51% needed hospital emergency care. Younger age; non-urgent acuity level; chest pain, ear, nose or throat problems; and injuries were independent predictors for self-referral. Most cited motives for self-referring were ‘accessibility and convenience’ and perceived ‘medical necessity’. Conclusions: A substantial part of the self-referrals needed hospital emergency care. The 49% self-referrals who were eligible for GP care presented during out-of-hours as well as during office hours. This calls for an integrative approach to this health care problem.@en

Introduction: To prevent overcrowding of the emergency department, a flexible acute admission unit (FAAU) was created, consisting of 15 inpatient regular beds located in different departments. We expected the FAAU to result in fewer transfers to other hospitals and in a lower length of stay (LOS) of patients needing hospital admission. Methods: A before-and-after interventional study was performed in a level 1 trauma center in the Netherlands. Number of transfers and LOS of admitted ED patients in a 4-month period in 2008 (control period) and a 4-month period in 2009 (intervention period) were analyzed. Results: Of 1,619 regular admission patients, 768 were admitted in the control period and 851 in the intervention period. The number of transfers decreased from 80 (10.42%) to 54 (6.35%) (P = .0037). The mean ED LOS of both the non-admitted patients and the admitted patients needing special care significantly increased (105 minutes vs 117 minutes [P = .022] and 176 minutes vs 191 minutes [P < .001], respectively). However, the mean LOS of FAAU-admissible patients was unaltered (226 minutes vs 225 minutes, P = .865). Conclusions: The FAAU reduced the number of transfers of admitted patients to other hospitals. The increase in LOS for special care patients and non-admitted patients was not observed for regular, FAAU-admissible patients. Flexible bed management might be useful in preventing overcrowding.@en

Introduction: To prevent overcrowding of the emergency department, a flexible acute admission unit (FAAU) was created, consisting of 15 inpatient regular beds located in different departments. We expected the FAAU to result in fewer transfers to other hospitals and in a lower length of stay (LOS) of patients needing hospital admission. Methods: A before-and-after interventional study was performed in a level 1 trauma center in the Netherlands. Number of transfers and LOS of admitted ED patients in a 4-month period in 2008 (control period) and a 4-month period in 2009 (intervention period) were analyzed. Results: Of 1,619 regular admission patients, 768 were admitted in the control period and 851 in the intervention period. The number of transfers decreased from 80 (10.42%) to 54 (6.35%) (P = .0037). The mean ED LOS of both the non-admitted patients and the admitted patients needing special care significantly increased (105 minutes vs 117 minutes [P = .022] and 176 minutes vs 191 minutes [P < .001], respectively). However, the mean LOS of FAAU-admissible patients was unaltered (226 minutes vs 225 minutes, P = .865). Conclusions: The FAAU reduced the number of transfers of admitted patients to other hospitals. The increase in LOS for special care patients and non-admitted patients was not observed for regular, FAAU-admissible patients. Flexible bed management might be useful in preventing overcrowding.@en

Introduction: To prevent overcrowding of the emergency department, a flexible acute admission unit (FAAU) was created, consisting of 15 inpatient regular beds located in different departments. We expected the FAAU to result in fewer transfers to other hospitals and in a lower length of stay (LOS) of patients needing hospital admission. Methods: A before-and-after interventional study was performed in a level 1 trauma center in the Netherlands. Number of transfers and LOS of admitted ED patients in a 4-month period in 2008 (control period) and a 4-month period in 2009 (intervention period) were analyzed. Results: Of 1,619 regular admission patients, 768 were admitted in the control period and 851 in the intervention period. The number of transfers decreased from 80 (10.42%) to 54 (6.35%) (P = .0037). The mean ED LOS of both the non-admitted patients and the admitted patients needing special care significantly increased (105 minutes vs 117 minutes [P = .022] and 176 minutes vs 191 minutes [P < .001], respectively). However, the mean LOS of FAAU-admissible patients was unaltered (226 minutes vs 225 minutes, P = .865). Conclusions: The FAAU reduced the number of transfers of admitted patients to other hospitals. The increase in LOS for special care patients and non-admitted patients was not observed for regular, FAAU-admissible patients. Flexible bed management might be useful in preventing overcrowding.@en

Introduction: To prevent overcrowding of the emergency department, a flexible acute admission unit (FAAU) was created, consisting of 15 inpatient regular beds located in different departments. We expected the FAAU to result in fewer transfers to other hospitals and in a lower length of stay (LOS) of patients needing hospital admission. Methods: A before-and-after interventional study was performed in a level 1 trauma center in the Netherlands. Number of transfers and LOS of admitted ED patients in a 4-month period in 2008 (control period) and a 4-month period in 2009 (intervention period) were analyzed. Results: Of 1,619 regular admission patients, 768 were admitted in the control period and 851 in the intervention period. The number of transfers decreased from 80 (10.42%) to 54 (6.35%) (P = .0037). The mean ED LOS of both the non-admitted patients and the admitted patients needing special care significantly increased (105 minutes vs 117 minutes [P = .022] and 176 minutes vs 191 minutes [P < .001], respectively). However, the mean LOS of FAAU-admissible patients was unaltered (226 minutes vs 225 minutes, P = .865). Conclusions: The FAAU reduced the number of transfers of admitted patients to other hospitals. The increase in LOS for special care patients and non-admitted patients was not observed for regular, FAAU-admissible patients. Flexible bed management might be useful in preventing overcrowding.@en

Introduction Emergency department (ED) crowding is a worldwide public health issue. In this study, patient flow and staff perceptions of crowding were assessed in Pakistan (Aga Khan University Hospital (AKUH)) and in the Netherlands (Haaglanden Medical Centre Westeinde (HMCW)). Bottlenecks affecting ED patient flow were identified. Methods First, a one-year review of patient visits was performed. Second, staff perceptions about ED crowding were collected using face-to-face interviews. Non-participant observation and document review were used to interpret the findings. Results At AKUH 58,839 (160 visits/day) and at HMCW 50,802 visits (140 visits/day) were registered. Length of stay (LOS) at AKUH was significantly longer than at HMCW (279 min (IQR 357) vs. 100 min (IQR 152)). There were major differences in patient acuities, admission and mortality rates, indicating a sicker population at AKUH. Respondents from both departments experienced hampered patient flow on a daily basis, and perceived similar causes for crowding: increased patients’ complexity, long treatment times, and poor availability of inpatient beds. Conclusion Despite differences in environment, demographics, and ED patient flow, respondents perceived similar bottlenecks in patient flow. Interventions should be tailored to specific ED and hospital needs. For both EDs, improving the outflow of boarded patients is essential.@en

OBJECTIVES: The aim of this study was to assess the walkout rate and to identify influencing patient and visit characteristics on walkout. Furthermore, we assessed the reasons for leaving and medical care needs after leaving. METHODS: In a 4-month population-based cohort study, the characteristics and influencing factors of walkout from two emergency departments in the Netherlands were studied. Afterwards, a follow-up telephone interview was conducted to assess the reasons for leaving and medical care needed. RESULTS: A total of 169 out of 23 780 (0.7%) registered patients left without treatment, of whom 62% left after triage. Of the triaged walkouts, 26% had urgent or highly urgent medical complaints and target times to treatment had elapsed for 54% of the triaged walkouts. Independent predictors of leaving without treatment included being self-referred, arriving during the evening or night or during crowded conditions, and relatively lower urgency triage allocation. Ninety (53%) walkouts were contacted afterwards by phone. Long waiting time (61%) was the most-cited prime reason for leaving. Medical problems had resolved spontaneously in 19 of the 90 (21%) walkouts, and 47 (52%) walkouts reported having sought medical care elsewhere. For 24 of the 90 (27%) walkouts with persisting complaints, medical care was advised during the follow-up telephone call. CONCLUSION: The average observed daily walkout rate was 1.4 patients over the 4-month period. In general, walkouts are self-referrals with lower urgent complaints, arriving during the evening or night shift or during crowded conditions. Most walkouts leave because of perceived long waiting times.@en

Introduction During emergency department (ED) crowding there is an imbalance between the need for emergency care and available resources. We assessed the impact of crowding on the triage process. Methods A 1-year health records review of 49,539 patient visits was performed. Data extracted included: occupancy ratio, ED occupancy, demographics, length of stay (LOS), time to triage, triage score, years working as a triage nurse, and triage destination. Data were analyzed using descriptive statistics and regression analyses. Results During crowding, target times to triage elapsed more often than during non-crowding (49.7% vs. 24.9%, P < 0.001), and more patients were not triaged (2.2% vs. 1.6%, P < 0.001). A higher ED occupancy was associated with longer waiting times for triage and longer LOS (P < 0.001). There were 12,627 (25.5%) patients redirected to the general practitioner cooperative (GPC). No association between level of crowdedness and number of patients who were redirected to the GPC was found (P = 0.122). Redirection to the GPC occurred significantly more often when the triage nurse had more years working as a triage nurse (P < 0.001). Conclusion At this hospital, crowding affects the triage process, leading to longer waiting times to triage and longer ED LOS. Crowding did not influence triage destination.@en