Background: Overcrowding in the emergency department (ED) is a global problem and a source of morbidity and mortality and exhaustion for the teams. Despite multiple strategies proposed to overcome overcrowding, the accumulation of patients lying in bed awaiting treatment or hospitalisation is often inevitable and a major obstacle to quality of care. We initiated a quality improvement project with the objective of zero patients lying in bed awaiting care/referral outside a care area.

Methods: Several plan-do-study-act (PDSA) cycles were tested and implemented to achieve and especially maintain the goal of having zero patients waiting for care outside the ED care area. The project team introduced and adapted five rules during these cycles: (1) no patients lying down outside of a care unit; (2) forward movement; (3) examination room always available; (4) team huddle and (5) an organisation overcrowding plan.

Results: Adaptation of ED organisation in the form of PDSA cycles allowed to obtain a collective team dimension to patient flow management. Since December 2021, despite an increase in activity, no patient is placed in a lying-in waiting area outside a care zone, irrespective of their care level. Vital distress and fragile patients who need to be kept in a supine position are treated immediately. In 2022, waiting time before medical contact was <2 hours for 90% of all patients combined.

Conclusions: The PDSA strategy based on these five measures allowed to remove in-house obstacles to the internal flow of patients and to fight against their installation outside the care area. These measures are easily replicable by other management teams. Quality indicators of EDs are often heterogeneous, but we propose that the absence of patients lying on a stretcher outside a care area could be part of these indicators, and thus contribute to the improvement and safety of care provided to all patients.