No single solution exists for alleviating crowding in emergency rooms, but a new study identifies four key strategies that have reduced the problem.

The study, published in the journal Annals of Emergency Medicine, concludes that engaged executive leadership can alleviate the problem when combined with a data–driven approach and coordination across the hospital from housekeepers to the CEO. Crowding in emergency rooms has been associated with decreased patient satisfaction and even death.

“Emergency department crowding can be dangerous for patients,” said senior author Benjamin Sun, MD, a professor of emergency medicine in the OHSU School of Medicine. “We know, for example, that emergency department crowding can lead to delays in pain medications for patients with broken bones, as well as delays in antibiotics for patients with pneumonia. We know the risk of death is higher when the emergency department is more crowded than when it’s less crowded.”

The study identified groups of hospitals categorized as low, high or highest–improving in terms of lengths of stay and boarding times (the length of time an admitted patient must wait for an inpatient bed), as measured through statistics provided by 2,619 U.S. hospitals to the Centers for Medicare and Medicaid Services. The authors picked a representative sample of four hospitals in each of the three categories of performance, then systematically interviewed a broad range of stakeholders.

The researchers talked to 60 people at the 12 hospitals. Interviewees included nursing staff, emergency department directors, directors of inpatient services, chief medical officers and other executive officers.