Causes and consequences of overcrowding in emergency departments and its impact on patients’ care at main governmental hospitals in Gaza Strip: a cross-sectional study

Abstract

Background

Emergency department (ED) overcrowding is a growing challenge in many healthcare systems, particularly in resource-limited settings such as the Gaza Strip. It negatively affects patient care quality, staff performance, and overall hospital efficiency. This study aimed to identify the main perceived causes and consequences of ED overcrowding in major governmental hospitals in Gaza and to assess its perceived impact on healthcare delivery.

Methods

A descriptive cross-sectional study was conducted among 289 healthcare professionals, including doctors (59.2%) and nurses (40.8%), working in the EDs of Al-Shifa Medical Complex, Nasser Medical Complex, European Gaza Hospital, and the Indonesian Hospital. Data were collected using a structured, self-administered questionnaire that assessed demographic characteristics, perceived causes, and consequences of overcrowding. Statistical analysis was performed using SPSS, employing descriptive statistics, independent t-tests, and one-way ANOVA to determine significant differences among participants’ responses.

Results

The most frequently perceived causes of overcrowding included the high number of non-emergency cases presenting to EDs (91%), inadequate staff salaries (90.8%), limited bed capacity (88.2%), and insufficient staffing (86.8%). Significant differences in perceptions were observed according to gender, profession, years of experience, workplace, and department (p < 0.001). The main perceived consequences were increased staff stress and workload (79.6%), reduced job satisfaction (82.6%), delayed patient care (76.8%), and increased risk of violence toward staff (82.6%).

Conclusion

Overcrowding in Gaza’s emergency departments is perceived as a complex and multifactorial problem that may affect healthcare delivery and staff wellbeing. Addressing this issue may require systemic interventions such as improving triage protocols, enhancing staffing and resource allocation, strengthening coordination between pre-hospital and ED services, and promoting public education on appropriate ED use to ensure timely and effective patient care.

Introduction

The Emergency Department (ED) is among the most congested hospital departments, admitting many patients with diverse medical problems, including those at high risk [1]. The primary objective of the Emergency Department is to address urgent and emergency situations requiring immediate intervention via swift diagnosis and the provision of medical or surgical treatment in a timely manner. The dysfunction of health services in the community has been shown to result in inadequate access to the emergency department, particularly among elderly and pediatric populations [1–3]. The congestion of emergency departments, sometimes termed overcrowding, has been recognized as an issue for prompt and effective care since the 1980s [4].

Overcrowding is defined as a condition in which the efficacy of the emergency department is hindered, primarily due to an excessive influx of patients awaiting consultation, diagnosis, treatment, transfer, or discharge; it is characterized by a disparity between supply and demand [5].

Overcrowding is primarily influenced by three factors: the influx of patients (input), the duration required to process and treat patients (throughput), and the number of patients exiting the emergency department (output) [6].

Among these criteria, patient boarding emerged as one of the most relevant [7]. Boarding refers to the retention of patients in the emergency department for extended durations owing to insufficient space on inpatient wards [7, 8]. Boarding and overcrowding adversely impact patient treatment, mortality, morbidity, patient satisfaction, and overall quality of care [4, 9, 10]. These factors also lead to an extended length of stay (LOS) in the ED, a heightened incidence of patients departing the ED without being evaluated (LWBS), and an escalation in medical mistakes [11–13].

The overcrowding of emergency departments has become a significant health issue, since the quantity of emergency departments is declining while the demand for emergency care is rising. Literature indicates that congestion mostly occurs in emergency departments with an annual visit volume over 40,000 [11, 14].

A precise assessment of crowding in the emergency department and an evidence-based comprehension of its effects are critical criteria prior to seeking remedies [6]. Despite the existence of several metrics for assessing varying levels of overcrowding, a definitive gold standard for quantifying this problem remains elusive. Literature indicates that overcrowding is characterized by three assessment indices: National Emergency Department Overcrowding Score (NEDOCS), Community Emergency Department Overcrowding Score (CEDOCS), and Severely-overcrowded-Overcrowded and Not-overcrowded Estimation Tool (SONET). The NEDOCS, developed by Weiss and associates [15], is the most often used score; it transforms a set of factors into a metric indicative of the level of overcrowding as seen by professionals engaged in their duties at that time. The scale ranges from 0 to 200 points, with a grade of 101 or above indicating overpopulation [16].

Ultimately, the measuring tools available for assessing congestion include ED occupancy, ED length of stay, ED volume, ED boarding time, number of boarders, waiting room count, and the Emergency Department Work Index (EDWIN) score. To devise effective remedies for overcrowding, it is crucial to comprehend its many origins and consequences, as well as to assess its tangible influence on the healthcare system [4].

This study is significant as it provides valuable insights into the underlying causes and far-reaching consequences of overcrowding in emergency departments within Gaza’s main governmental hospitals—an issue that directly impacts patient safety, quality of care, and healthcare staff performance. By identifying key factors contributing to overcrowding and its effects on clinical outcomes and work environments, the study aimed to inform evidence-based strategies and policy interventions to improve emergency care efficiency and patient management.

Methods

Study design

This study employed a descriptive cross-sectional design to assess the causes and consequences of overcrowding in EDs and its perceived impact on patient care in the main governmental hospitals of the Gaza Strip. The design was chosen to obtain a comprehensive overview of healthcare professionals’ perceptions and experiences regarding ED overcrowding within a defined time frame.

Study setting

The study was conducted in the EDs of the four main governmental hospitals in the Gaza Strip: Al-Shifa Medical Complex, Nasser Medical Complex, European Gaza Hospital, and the Indonesian Hospital during the period from January to March 2023. These hospitals serve as the primary referral centers for emergency care across Gaza’s governorates. Each hospital’s ED includes separate medical and surgical sections, and most departments experience high patient inflow, with an estimated daily attendance ranging from 250 to 400 patients depending on the facility. Space limitations, shortage of beds, and high staff-to-patient ratios characterize these departments, contributing to frequent overcrowding episodes.

Population and sampling

The target population included doctors and nurses working in the emergency departments of the selected hospitals. Participants were eligible if they had at least six months of experience working in the ED. Administrative staff, interns, and trainees were excluded to ensure professional experience relevance.

A total of 289 participants were recruited, including 171 doctors (59.2%) and 118 nurses (40.8%). A convenience sampling method was used due to staff shift variability and workload constraints. Efforts were made to ensure representation across day, evening, and night shifts, and both medical and surgical ED sections.

The sample size was determined based on the total estimated number of ED staff across the four hospitals (~ 400 professionals), using an expected response proportion of 50%, a 95% confidence level, and a 5% margin of error, yielding a minimum required sample of approximately 197 participants. The final sample of 289 represents a response rate of about 72%.

Data collection

Data were collected between January to March 2023 using a self-administered structured questionnaire distributed in person by trained data collectors. Eligible participants were approached during their working hours, and those willing to participate were given the questionnaire to complete in a confidential space within the ED during break times. Completed forms were collected on the same day to ensure high response quality and confidentiality.

Instrument

The questionnaire was adapted from validated instruments used in prior studies on emergency department overcrowding [12, 13] and modified to suit the Gaza context. It comprised three main sections:

• Demographic and professional characteristics

• Perceived causes of overcrowding: This domain assesses respondents’ views on the factors they believe contribute to overcrowding in emergency departments, such as patient flow issues, limited resources, staff shortages, or delays in diagnostic and treatment processes.

• Perceived consequences of overcrowding: This domain measures respondents’ perceptions of the outcomes or impacts resulting from overcrowding in emergency departments, including effects on quality of care, patient safety, waiting times, staff workload, and overall patient experience.

All items were measured using a five-point Likert scale ranging from 1 = strongly disagree to 5 = strongly agree. The estimated completion time was 10–15 min, and the questionnaire was paper-based to accommodate limited electronic resources.

As English is the professional working language among healthcare staff in Gaza’s governmental hospitals, translation was not required. The instrument’s content validity was reviewed by a panel of five experts in emergency medicine and public health. Internal consistency was confirmed using Cronbach’s alpha coefficients of 0.87 for the causes scale and 0.89 for the consequences scale, indicating high reliability.

Statistical analysis

Data were coded and analyzed using IBM SPSS Statistics version 23.0. Descriptive statistics (means, standard deviations, and frequencies) were used to summarize participant characteristics and responses. The Kolmogorov–Smirnov test was applied to assess normality assumptions for continuous variables before conducting parametric tests. Comparisons between groups were performed using independent-samples t-tests and one-way ANOVA, as appropriate. A p-value < 0.05 was considered statistically significant. Missing data represented less than 2% of total responses and were handled using pairwise deletion.

Validity and reliability

The questionnaire used in this study demonstrated high internal consistency, with Cronbach’s alpha coefficients of 0.87 for the causes scale and 0.89 for the consequences scale, indicating good reliability. Content validity was established through expert review by five professionals in emergency medicine and public health, who assessed the relevance, clarity, and comprehensiveness of the items. The instrument was adapted from previously validated questionnaires in the literature [12, 13] and reviewed to ensure suitability for the local context, preserving the English language as it is the professional working language of participants.

Ethical considerations

Ethical approval was obtained from the Faculty of Medicine, Islamic University of Gaza, and subsequently from the Department of Health Research, Ministry of Health–Gaza. Participation was voluntary, and informed consent was obtained from all participants. Anonymity and confidentiality were strictly maintained throughout the study, and all data were used solely for academic and research purposes. Research was conducted according to the research ethics and regulations at the Faculty of Medicine at based on Health Research Department at the Ministry of Health. This study was conducted in full compliance with the ethical principles of the Declaration of Helsinki.

Results

Baseline characteristics of study participants

The study included 289 participants of both doctors and nurses working in the emergency departments (ED) of the main hospitals in Gaza Strip. The mean age of study participants was 29.45 ± 3.86 years and ranged from 24 to 49 years. There were 168 male participants (58.1%) and 121 female participants (41.9%). Study participants were either doctors (n = 171, 59.2%) or nurses (n = 118, 40.8%).

Participants had worked for different duration at the emergency department. The most frequent duration was less than 2 years (n = 141, 48.8%). Nurses participants in this study had worked more at the emergency department that doctors (P = 0.001).

Participants were working at emergency departments of the main governmental hospitals in Gaza Strip. About half of participants were working in Shifa Medical Complex (n = 141, 48.8%). More than half of study participants were working for both surgical and medical emergency department (n = 164, 56.7%). On the other hand, there were 68 participants working at surgical ED (23.5%) and 57 participants working at medical ED (19.7%). Table 1 summarizes baseline characteristics of study participants.

Table 1.

Characteristics of study participants

Variable	Category	Frequency (n)	Percentage (%)
Gender	Male	168	58.1
	Female	121	41.9
Profession	Doctor	171	59.2
	Nurse	118	40.8
Age (years)	Mean ± SD	29.45 ± 3.86	Range: 24–49
Years of experience in ED	< 2 years	141	48.7
	2–4 years	91	31.5
	5–10 years	46	16
	> 10 years	11	3.8
Hospital	Shifa Medical Complex	141	49
	Nasser Medical Complex	44	15
	European Gaza Hospital	52	18
	Indonesian Hospital	52	18
ED Department	Both surgical & medical	164	56.7
	Surgical only	68	23.5
	Medical only	57	19.7

Causes of overcrowding at emergency departments

Table 2 summarized the distribution of the study participants according to their answers about the causes of overcrowding in the emergency departments. Furthermore, this table demonstration that the weighted mean for the overall perceptions about causes of overcrowding in the emergency departments was 77.6%. According to the finding, the highest item was number (11) ‘” ‘Patients seen at the ED are coming for non-emergent complain” with a score equal to 91%, followed by item number (22) “Inadequate ED Staff Salary” with a score equal 90.8%. While the lowest item (18) “Radiology delays” with a score equal to 64.2%, followed by item was the number (16) “Inadequate care provided form the response teams like Paramedics” with a score equal 67.8%. There were statistical differences in the participants’ responses owing to their characteristics. Table 3 displays the average difference between the examined domains (causes) in relation to participants’ characteristics. The one-way ANOVA test and independent samples t test revealed that there were statistically significant differences among all variables and the level of agreement on the causes on overcrowding in the emergency departments (P < 0.001).

Table 2.

Scores of items measuring participants responses to causes of overcrowding at the emergency departments

No.	Items	Mean	SD	% Mean	Rank
1	Limited Beds in the Emergency Department	4.14	0.882	88.2	8
2	Limited Staff Members in the Emergency Department	4.34	0.88	86.8	4
3	Limited Support Staff in the Emergency Department	3.96	0.984	79.2	9
4	Limited Space in the Emergency Department	4.23	0.905	84.6	5
5	Ineffective ED triage system	3.77	1.093	75.4	16
6	Lengthy Bureaucratic Procedures	3.44	0.992	68.8	22
7	Seen Patients in the ED stay longer than expected	3.67	1.075	73.4	19
8	Requesting Unnecessary Investigations	3.41	1.148	68.2	23
9	Poor Doctors Call System	3.73	1.007	74.6	17
10	Cases Seen in the ED are Complicated or Multi-trauma	3.89	0.817	77.8	10
11	Patents Seen at the ED are coming for a non-Emergent Complain	4.55	0.681	91	1
12	Lack of protocols for common & regular ED Complaints	3.82	1.016	76.4	15
13	The Presence of Students & Trainees at the ED	3.53	1.102	70.6	21
14	Lack of Communication and Coordination between Ambulances and the ED	3.55	1.107	71	20
15	Dysfunctional or dated Architectural Lay-out of the ED	3.85	1.033	77	13
16	Inadequate care provided form the response teams like Paramedics	3.39	1.113	67.8	24
17	Inadequate ED equipment to use like stretchers	3.68	1.007	73.6	18
18	Radiology delays	3.21	1.154	64.2	25
19	Laboratory delays	3.87	1	77.4	11
20	Consultation delays	3.86	0.925	77.2	12
21	Inadequate refreshment facilities (bathrooms, gardens, kitchens, rooms, Etc.) in ED	4.17	0.986	83.4	7
22	Inadequate ED Staff Salary	4.54	0.794	90.8	2
23	Allowing more than one family companion to enter the ED with patients	4.36	1.134	87.2	3
24	Lack of Security	4.18	0.941	83.6	6
25	Limited Staff during Weekends	3.84	1.036	76.8	14
Total		3.88	0.362	77.6

Table 3.

Statistical relationship between participants’ characteristics and responses to causes of overcrowding in the emergency department scale

Variable		Mean	SD	t*/F**	P value
Gender	Male	4.11	0.923	-3.77	< 0.001
	Female	4.18	0.82
Profession	Doctor	4.24	0.738	12.008	< 0.001
	Nurse	4	1.035
Working years	Less than 2 Years	4.13	0.864	35.357	< 0.001
	2–4 Years	4.2	0.832
	5–10 Years	4.18	0.863
	More than 10 years	3.72	1.272
Working place	SMC	4.27	0.806	32.69	< 0.001
	NMC	3.49	0.998
	EGH	4.11	0.796
	IH	4.35	0.805
Department	Surgical	4.18	0.766	41.99	< 0.001
	Medical	4.29	0.811
	Both	4.07	0.941

SD: Standard Deviation; *Independent T test; **One Way ANOVA; SMC: Shifa Medical Complex; NMC: Nasser Medical Complex; EGH: European Gaza Hospital; IH: Indonesian Hospital

Consequences of overcrowding at emergency departments

Table 4 summarized the distribution of the study participants according to their answers about the consequences of overcrowding in the emergency departments. Furthermore, this table demonstration that the weighted mean for the overall perceptions about consequences of overcrowding in the emergency departments was 74.2%. According to the finding, the highest item were number (6)” Decrease staff job satisfaction” and number (11) “Increase chances of violent confrontation between families and the ED staff” with a score equal to 82.6% and item number, followed by item number (3) “Increasing stress and workload among physicians” with a score equal 79.6%. While the lowest item (13) “Missing out some patients in urgent need for assessment and intervention” with a score equal to 65%, followed by item was the number (20) “Increased ambulance diversion” with a score equal 67.2%. There were statistical differences in the participants’ responses owing to their characteristics. Table 5 displays the average difference between the examined domains (consequences) in relation to participants’ characteristics. The one-way ANOVA test and independent samples t test revealed that there were statistically significant differences among all variables except for profession (P = 0.357) and the level of agreement on the consequences on overcrowding in the emergency departments (P < 0.001).

Table 4.

Scores of items measuring participants responses to consequences of overcrowding at the emergency departments

No.	Items	Mean	SD	% Mean	Rank
1	Increasing morbidity and mortality	3.55	0.977	71	14
2	Increasing stress and workload among nurses	3.94	0.948	78.8	3
3	Increasing stress and workload among physicians	3.98	0.987	79.6	2
4	Delays in discharge	3.84	0.85	76.8	5
5	Increase disputes and disagreements between different medical specialties	3.9	0.826	78	5
6	Decrease staff job satisfaction	4.13	0.79	82.6	1
7	Inaccurate or incomplete patient assessment	3.61	0.951	72.2	12
8	Poor documentation process	3.72	1.001	74.4	8
9	Delay in transferring admitted patients from the ED to appropriate inpatient units	3.69	1.051	73.8	10
10	Decrease patient satisfaction	3.82	0.928	76.4	7
11	Increase chances of violent confrontation between families and the ED staff	4.13	0.857	82.6	1
12	Poor handover of patients between shifts	3.51	1.02	70.2	17
13	Missing out some patients in urgent need for assessment and intervention	3.25	1.173	65	19
14	Increase risk of poor patient outcome	3.53	0.958	70.6	15
15	Increase chances of medical errors	3.55	0.981	71	14
16	Friction between disciplines and inter professional clashes	3.68	0.92	73.6	11
17	Long waiting time in ED	3.83	1.067	76.6	6
18	Decreased ability to protect patient privacy and confidentiality	3.52	1.11	70.4	16
19	Increased harm to hospitals due to financial losses	3.6	1.066	72	13
20	Increased ambulance diversion	3.36	1.009	67.2	18
21	This increased length of stay means an increased cost per patient	3.71	1.069	74.2	9
Total		3.71	0.231	74.2

Table 5.

Statistical relationship between participants’ characteristics and responses to consequences of overcrowding in the emergency department scale

Variable		Mean	SD	t*/F**	P value
Gender	Male	3.62	0.979	7.631	< 0.001
	Female	3.46	0.968
Profession	Doctor	3.54	0.994	-0.921	0.357
	Nurse	3.56	0.954
Working years	Less than 2 Years	3.57	0.958	17.09	< 0.001
	2–4 Years	3.61	0.986
	5–10 Years	3.4	1.043
	More than 10 years	3.48	0.774
Working place	SMC	3.74	0.891	29.49	< 0.001
	NMC	3.47	0.868
	EGH	2.92	1.021
	IH	3.7	0.992
Department	Surgical	3.7	0.961	54.95	< 0.001
	Medical	3.64	0.925
	Both	3.46	0.991

SD: Standard Deviation; *Independent T test; **One Way ANOVA; SMC: Shifa Medical Complex; NMC: Nasser Medical Complex; EGH: European Gaza Hospital; IH: Indonesian Hospital

Discussion

The findings of this study highlight the critical and persistent problem of overcrowding in emergency departments (EDs) across the main governmental hospitals in the Gaza Strip. Overcrowding was perceived to stem largely from preventable factors such as the high influx of non-emergency cases, limited bed capacity, and insufficient staffing levels, which collectively strain available resources. These perceptions are consistent with findings from previous studies conducted in similar low-resource and conflict-affected settings, where inadequate infrastructure, delayed investigations, and weak referral systems were also identified as major contributors to patient congestion. Moreover, the observed differences in perceptions among healthcare professionals according to gender, experience, and workplace indicate that varying working conditions and professional exposures shape individual understanding of the overcrowding phenomenon.

The perceived consequences of overcrowding in this study extend beyond logistical challenges to include serious implications for patient safety and staff wellbeing. Participants reported increased stress, reduced job satisfaction, delayed care, and heightened risks of violence and medical errors—all of which reflect a deteriorating emergency care environment. These findings suggest that overcrowding is viewed not merely as an operational concern but as a systemic issue perceived to affect overall healthcare delivery quality. Addressing this challenge may require a comprehensive strategy that includes improved triage systems, stronger communication between emergency and pre-hospital services, targeted staff training, and equitable workload distribution. In addition, enhancing administrative efficiency and public awareness about appropriate ED use could help mitigate the influx of non-urgent cases and optimize the use of limited resources.

The results of this study support the understanding that ED overcrowding is a multifactorial and complex phenomenon that can be explained through the input–throughput–output model, where each stage contributes independently yet interactively to patient flow inefficiencies [10, 17, 18]. Input factors, which represent the volume and type of patients arriving at the ED, were perceived to include an increasing number of nonurgent visits, aging populations, and limited access to primary or community healthcare services [10, 19, 20]. Inappropriate ED use—such as frequent visits by patients with minor complaints—was also seen as aggravating crowding [20, 21]. Furthermore, the presence of multiple escorts accompanying patients was perceived to negatively affect workflow efficiency and staff performance [18]. Previous studies have reported similar associations between overcrowding and unnecessary admissions, particularly among less severe cases, which can burden hospital resources and delay care for critically ill patients [22, 23].

Throughput factors, relating to internal ED processes, were also perceived to significantly influence patient length of stay and departmental flow [10]. Participants identified delays in diagnostic results, prolonged consultations, low staffing levels, and inadequate coordination among staff as key contributors to inefficiency [20, 21]. When hospital resources—such as medical staff, diagnostic services, or beds—do not match patient demand, bottlenecks may occur, causing further congestion and delays [6, 19, 20]. Output factors, mainly associated with the difficulty of transferring patients out of the ED, were perceived as major drivers of crowding. Limited inpatient bed capacity, exit block, and boarding were common issues reported to prolong stays, reduce bed turnover, and compromise patient management [10, 20]. Prior research has shown that these challenges increase waiting times, the likelihood of patients leaving before evaluation, and the risk of adverse outcomes [10]. The COVID-19 pandemic further exacerbated these issues, as new infection control protocols, screening requirements, and segregation of COVID and non-COVID cases contributed to longer hospitalization processes and reduced ED efficiency [1, 10, 24–27].

The perceived consequences of overcrowding extend beyond patient flow management, encompassing effects on both patient outcomes and healthcare provider wellbeing. Longer waiting times have been associated in prior literature with higher rates of patients leaving without being seen (LWBS), delayed diagnoses, and increased mortality among critical cases such as myocardial infarction [2, 28]. Overcrowding has also been linked to compromised care quality, greater risk of medical errors, and higher rates of hospital-acquired infections [29, 30]. Healthcare professionals working under overcrowded conditions often experience higher stress levels, diminished job satisfaction, and increased turnover [2, 31]. From an economic perspective, overcrowding has been associated with greater healthcare costs due to repeated visits, avoidable admissions, and extended hospital stays, with boarding alone estimated to substantially increase expenditures [2, 32–34]. Moreover, return visits—often linked to premature discharge or diagnostic delays—were perceived to further strain available resources and diminish care efficiency [35–37].

To mitigate ED overcrowding, both microlevel and macrolevel strategies have been recommended in the literature [4, 10]. Microlevel approaches include fast-tracking low-acuity cases, implementing observation units, enhancing triage systems, and integrating digital or artificial intelligence–based solutions to improve decision-making and patient flow. At the macrolevel, broader hospital and policy reforms are needed—such as simplifying admission and discharge processes, ensuring weekend discharges, and applying full-capacity protocols to distribute patient loads more evenly across departments [4, 10]. Coordinated implementation of these measures may enhance system efficiency and help EDs provide safer and more timely patient care.

The ongoing war in Gaza has profoundly impacted not only healthcare delivery but also the psychological wellbeing of both healthcare workers and the general population. The constant exposure to violence, mass casualties, and resource scarcity has created a setting of chronic stress and psychological strain. This has likely contributed to the challenges observed in emergency departments, where overcrowding, limited resources, and high workloads intersect with the psychological toll of working under siege and war conditions. Previous studies have documented elevated rates of post-traumatic stress disorder (PTSD), depression, and anxiety among Gaza’s population, including frontline healthcare providers who face continuous traumatic exposure and moral injury. These mental health burdens further exacerbate staffing challenges and reduce workforce resilience, intensifying the overcrowding crisis. Addressing ED overcrowding in Gaza therefore requires not only structural and administrative solutions but also integrated psychosocial support and context-sensitive mental health interventions that strengthen resilience and sustain healthcare providers’ capacity to function effectively during ongoing conflict [38].

It is important to note that, as a cross-sectional observational study, the findings reflect associations and perceived impacts rather than causal relationships. While the study highlights key factors contributing to ED overcrowding, interpretations should be made cautiously. The unique context of the Gaza Strip—characterized by ongoing conflict, high rates of mass casualty events, and limited healthcare resources—likely exacerbates ED congestion and places additional stress on staff, which may not be generalizable to other non-conflict settings. Despite these limitations, the study provides valuable insight into how overcrowding is perceived by frontline healthcare professionals and may inform strategies in other conflict-affected or resource-limited settings. Future research employing longitudinal or multi-center designs could better assess trends, causal factors, and the effectiveness of targeted interventions.

This study has several methodological limitations that should be considered when interpreting the findings. The use of a descriptive cross-sectional design restricts the ability to infer causality between identified factors and overcrowding outcomes. Convenience sampling may introduce selection bias, as participants who were available and willing to respond may differ from those who were not, particularly given the heavy workload and shift rotations in emergency departments. The data were self-reported, which may be influenced by personal perceptions, recall bias, or social desirability. Additionally, the study was conducted in four governmental hospitals in the Gaza Strip, which may limit the generalizability of results to other healthcare settings with different structures, resources, or patient flow patterns. Despite these limitations, the study provides valuable insights into healthcare professionals’ perceptions of ED overcrowding in a high-demand, resource-constrained environment.

Conclusion

This study demonstrated that overcrowding in emergency departments across Gaza’s main governmental hospitals is a multifactorial challenge, perceived to result from the high influx of non-urgent patient visits, limited bed capacity, and inadequate staffing and resources. These conditions were perceived to negatively affect both patient care and staff wellbeing through increased workload, stress, treatment delays, and reduced job satisfaction. To address these challenges, immediate and practical measures are needed. Public awareness campaigns should be launched to educate the community on the appropriate use of emergency departments and to encourage the use of primary healthcare services for non-urgent cases. In addition, there is a need to review and improve staff compensation, retention, and workload distribution to ensure adequate support for healthcare professionals working under high-pressure conditions. Rapid-track systems and standardized triage protocols should also be established to streamline patient flow, prioritize critical cases, and minimize waiting times. Furthermore, enhanced coordination between emergency departments and pre-hospital services is essential to improve referral processes and optimize the use of available resources. Implementing these targeted interventions could help mitigate overcrowding and strengthen the overall efficiency, safety, and quality of emergency care delivery in Gaza and other resource-limited, conflict-affected settings.

Abbreviations

Abbreviation

Full Form

ED

Emergency Department

LOS

Length of Stay

LWBS

Left Without Being Seen

NEDOCS

National Emergency Department Overcrowding Score

CEDOCS

Community Emergency Department Overcrowding Score

SONET

Severely-overcrowded–Overcrowded and Not-overcrowded Estimation Tool

EDWIN

Emergency Department Work Index

SPSS

Statistical Package for the Social Sciences

SMC

Shifa Medical Complex

NMC

Nasser Medical Complex

EGH

European Gaza Hospital

IH

Indonesian Hospital

SD

Standard Deviation

NGO

Non-Governmental Organization

Author contributions

Hasan Hamdan, Khaled Siyam, Ahmed Eid, Baraa Astal, Mohammed Abdelghafour, and Jameel Wafi were responsible for data collection and contributed to the preparation of the research proposal. Tayseer Afifi performed the data analysis and wrote the manuscript. Khamis Elessi supervised all stages of the research process, including study design, data interpretation, and manuscript revision. All authors reviewed and approved the final version of the manuscript prior to submission.

Funding

None.

Data availability

Data are available upon reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval was obtained from the department of health research at the ministry of health in Gaza after gaining an ethical approval from the faculty of medicine at Islamic University of Gaza. Participation was voluntary, and informed consent was obtained from all participants. Anonymity and confidentiality of the data were maintained throughout the research process, and the information collected was used solely for academic and research purposes. Research was conducted according to the research ethics and regulations at the Faculty of Medicine at based on Health Research Department at the Ministry of Health. This study was conducted in full compliance with the ethical principles of the Declaration of Helsinki.

Consent for publication

Consent for publication was not applicable.

Competing interests

The authors declare no competing interests.