The Impact of Crowding on Time until Abdominal CT Interpretation in Emergency Department Patients with Acute Abdominal Pain

Emergency Department Volume, Severity, and Crowding Since the Onset of the Coronavirus Disease 2019 Pandemic

STUDY OBJECTIVE

We describe emergency department (ED) visit volume, illness severity, and crowding metrics from the onset of the coronavirus disease 2019 (COVID-19) pandemic through mid-2022.

METHODS

We tabulated monthly data from 14 million ED visits on ED volumes and measures of illness severity and crowding from March 2020 through August 2022 compared with the same months in 2019 in 111 EDs staffed by a national ED practice group in 18 states.

RESULTS

Average monthly ED volumes fell in the early pandemic, partially recovered in 2022, but remained below 2019 levels (915 per ED in 2019 to 826.6 in 2022 for admitted patients; 3,026.9 to 2,478.5 for discharged patients). The proportion of visits assessed as critical care increased from 7.9% in 2019 to 11.0% in 2022, whereas the number of visits decreased (318,802 to 264,350). Visits billed as 99285 (the highest-acuity Evaluation and Management code for noncritical care visits) increased from 35.4% of visits in 2019 to 40.0% in 2022, whereas the number of visits decreased (1,434,454 to 952,422). Median and median of 90th percentile length of stay for admitted patients rose 32% (5.2 to 6.9 hours) and 47% (11.7 to 17.4 hours) in 2022 versus 2019. Patients leaving without treatment rose 86% (2.9% to 5.4%). For admitted psychiatric patients, the 90th percentile length of stay increased from 20 hours to more than 1 day.

CONCLUSION

ED visit volumes fell early in the pandemic and have only partly recovered. Despite lower volumes, ED crowding has increased. This issue is magnified in psychiatric patients.

Measures of Emergency Department Crowding, a Systematic Review. How to Make Sense of a Long List

Emergency department (ED) crowding, a common and serious phenomenon in many countries, lacks standardized definition and measurement methods. This systematic review critically analyzes the most commonly studied ED crowding measures. We followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. We searched PubMed/Medline Database for all studies published in English from January 1st, 1990, until December 1st, 2020. We used the National Institute of Health (NIH) Quality Assessment Tool to grade the included studies. The initial search yielded 2293 titles and abstracts, of whom we thoroughly reviewed 109 studies, then, after adding seven additional, included 90 in the final analysis. We excluded simple surveys, reviews, opinions, case reports, and letters to the editors. We included relevant papers published in English from 1990 to 2020. We did not grade any study as poor and graded 18 as fair and 72 as good. Most studies were conducted in the USA. The most studied crowding measures were the ED occupancy, the ED length of stay, and the ED volume. The most heterogeneous crowding measures were the boarding time and number of boarders. Except for the National ED Overcrowding Scale (NEDOCS) and the Emergency Department Work Index (EDWIN) scores, the studied measures are easy to calculate and communicate. Quality of care was the most studied outcome. The EDWIN and NEDOCS had no studies with the outcome mortality. The ED length of stay had no studies with the outcome perception of care. ED crowding was often associated with worse outcomes: higher mortality in 45% of the studies, worse quality of care in 75%, and a worse perception of care in 100%. The ED occupancy, ED volume, and ED length of stay are easy to measure, calculate and communicate, are homogenous in their definition, and were the most studied measures.

Impact of Emergency Department Crowding on Delays in Acute Stroke Care

Introduction

Delays in identification and treatment of acute stroke contribute to significant morbidity and mortality. Multiple clinical factors have been associated with delays in acute stroke care. We aimed to determine the relationship between emergency department (ED) crowding and the delivery of timely emergency stroke care.

Methods

We used prospectively collected data from our institutional Get with the Guidelines-Stroke registry to identify consecutive acute ischemic stroke patients presenting to our urban academic ED from July 2016–August 2018. We used capacity logs to determine the degree of ED crowding at the time of patients’ presentation and classified them as ordinal variables (normal, high, and severe capacity constraints). Outcomes of interest were door-to-imaging time (DIT) among patients potentially eligible for alteplase or endovascular therapy on presentation, door-to-needle time (DTN) for alteplase delivery, and door-to-groin puncture (DTP) times for endovascular therapy. Bivariate comparisons were made using t-tests, chi-square, and Wilcoxon rank-sum tests as appropriate. We used regression models to examine the relationship after accounting for patient demographics, transfer status, arrival mode, and initial stroke severity by the National Institutes of Health Stroke Scale.

Results

Of the 1379 patients with ischemic stroke presenting during the study period, 1081 (78%) presented at times of normal capacity, 203 (15%) during high ED crowding, and 94 (7%) during severe crowding. Median DIT was 26 minutes (interquartile range [IQR] 17–52); DTN time was 43 minutes (IQR 31–59); and median DTP was 58.5 minutes (IQR 56.5–100). Treatment times were not significantly different during periods of higher ED utilization in bivariate or in multivariable testing.

Conclusion

In our single institution analysis, we found no significant delays in stroke care delivery associated with increased ED crowding. This finding suggests that robust processes of care may enable continued high-quality acute care delivery, even during times with an increased capacity burden.

Temporal trends in emergency department volumes and crowding metrics in a western Canadian province: a population-based, administrative data study

Background

Emergency Department (ED) crowding is a pervasive problem, yet there have been few comparisons of the extent of, and contributors to, crowding among different types of EDs. The study quantifies and compares crowding metrics for 16 high volume regional, urban and academic EDs in one Canadian province.

Methods

The National Ambulatory Care Reporting System (NACRS) provided ED presentations by adults to 16 high volume Alberta EDs during April 2010 to March 2015 for this retrospective cohort study. Time to physician initial assessment (PIA), length of stay (LOS) for discharges and admissions were grouped by start hour of presentation and facility. Multiple crowding metrics were created by taking the means, medians (PIA-M, LOS-M), and 90th percentiles of the hourly, ED-specific values. Similarly, proportion left against medical advice (LAMA) and proportion left without being seen (LWBS) were day and ED aggregated. Calculated based on the start of the presentation and the facility and for PIA and LOS. The mean, median, and 90th percentiles for the date and time ED-specific metrics for PIA and LOS were obtained. Summary statistics were used to describe crowding metrics.

Results

There were 3,925,457 presentations by 1,420,679 adults. The number of presentations was similar for each sex and the mean age was 46 years. Generally, the three categories of EDs had similar characteristics; however, urban and academic/teaching EDs had more urgent triage scores and a higher percentage of admissions than regional EDs. The median of the PIA-M metric was 1 h23m across all EDs. For discharges, the median of the LOS-M metric was 3h21m whereas the median of the LOS-M metric for admissions was 10h08m. Generally, regional EDs had shorter times than urban and academic/teaching EDs. The median daily LWBS was 3.4% and the median daily LAMA was about 1%.

Conclusions

Emergency presentations have increased over time, and crowding metrics vary considerably among EDs and over the time of day. Academic/teaching EDs generally have higher crowding metrics than other EDs and urgent action is required to mitigate the well-known consequences of ED crowding.

Impact of Emergency Department Tele-intake on Left Without Being Seen and Throughput Metrics

OBJECTIVES

More than 2 million patients present to a U.S. emergency department (ED) annually and leave without being seen (LWBS) due to delays in initiating care. We evaluated whether tele-intake at the time of presentation would reduce LWBS rates and ED throughput measures.

METHODS

We conducted a before-and-after study at an urban community hospital. The intervention was use of a tele-intake physician to triage patients from 11 am to 6 pm, 7 days per week. Tele-intake providers performed a triage history and physical examination, documented findings, and initiated orders in the medical record. We assessed the impact of this program using the domains of the National Quality Forum framework evaluating access, provider experience, and effectiveness of care. The main outcome was 24-hour LWBS rate. Secondary outcomes were overall door to provider and door to disposition times, left without treatment complete (LWTC), left against medical advice (AMA), left without treatment (LWOT), and physician experience. We compared the 6-month tele-intake period to the same period from the prior year (October 1 to April 1, 2017 vs. 2016). Additionally, we conducted a survey of our physicians to assess their experience with the program.

RESULTS

Total ED volume was similar in the before and after periods (19,892 patients vs. 19,646 patients). The 24-hour LWBS rate was reduced from 2.30% (95% confidence interval [CI] = 2.0% to 2.5%) to 1.69% (95% CI = 1.51% to 1.87%; p < 0.001). Overall door to provider time decreased (median = 19 [interquartile range {IQR} = 9 to 38] minutes vs. 16.2 [IQR = 7.8 to 34.3] minutes; p < 0.001), but ED length of stay for all patients (defined as door in to door out time for all patients) minimally increased (median = 184 [IQR = 100 to 292] minutes vs. 184.3 [IQR = 104.4 to 300] minutes; p < 0.001). There was an increase in door to discharge times (median = 146 [IQR = 83 to 231] minutes vs. 148 [IQR = 88.2 to 233.6] minutes; p < 0.001) and door to admit times (median = 330 [IQR = 253 to 432] minutes vs. 357.6 [IQR = 260.3 to 514.5] minutes; p < 0.001). We saw an increase in LWTC (0.59% [95% CI = 0.49% to 0.70%] vs. 1.1% [95% CI = 0.9% to 1.2%]; p < 0.001), but no change in AMA (1.4% [95% CI = 1.2% to 1.6%] vs. 1.6% [95% CI = 1.4% to 1.78%]; p = 0.21) or LWOT (4.3% [95% CI = 4.1% to 4.6%] vs. 4.4% [95% CI = 4.1% to 4.7%]; p = 0.7). Tele-intake providers thought tele-intake added value (12/15, 80%) and allowed them to effectively address medical problems (14/15, 95%), but only (10/15, 67%) thought that it was as good as in-person triage. Of the receiving physicians, most agreed with statements that tele-intake did not interfere with care (19/22, 86%), helped complement care (19/21, 90%), and gave the patient a better experience (19/22, 86%).

CONCLUSIONS

Remote tele-intake provided in an urban community hospital ED reduced LWBS and time to provider but increased LWTC rates and had no impact on LWOT.

Challenges, consequences, and lessons for way-outs to emergencies at hospitals: a systematic review study

Background

Emergency Department (ED) overcrowding adversely affects patients’ health, accessibility, and quality of healthcare systems for communities. Several studies have addressed this issue. This study aimed to conduct a systematic review study concerning challenges, lessons and way outs of clinical emergencies at hospitals.

Methods

Original research articles on crowding of emergencies at hospitals published from 1st January 2007, and 1st August 2018 were utilized. Relevant studies from the PubMed and EMBASE databases were assessed using suitable keywords. Two reviewers independently screened the titles, abstracts and the methodological validity of the records using data extraction format before their inclusion in the final review. Discussions with the senior faculty member were used to resolve any disagreements among the reviewers during the assessment phase.

Results

Out of the total 117 articles in the final record, we excluded 11 of them because of poor quality. Thus, this systematic review synthesized the reports of 106 original articles. Overall 14, 55 and 29 of the reviewed refer to causes, effects, and solutions of ED crowding, respectively. The review also included four articles on both causes and effects and another four on causes and solutions. Multiple individual patients and healthcare system related challenges, experiences and responses to crowding and its consequences are comprehensively synthesized.

Conclusion

ED overcrowding is a multi-facet issue which affects by patient-related factors and emergency service delivery. Crowding of the EDs adversely affected individual patients, healthcare delivery systems and communities. The identified issues concern organizational managers, leadership, and operational level actions to reduce crowding and improve emergency healthcare outcomes efficiently.

Utility of multiple rule out CT screening of high-risk atraumatic patients in an emergency department-a feasibility study

BACKGROUND

Several large trials have evaluated the effect of CT screening based on specific symptoms, with varying outcomes. Screening of patients with CT based on their prognosis alone has not been examined before. For moderate-to-high risk patients presenting in the emergency department (ED), the potential gain from a CT scan might outweigh the risk of radiation exposure. We hypothesized that an accelerated "multiple rule out" CT screening of moderate-to-high risk patients will detect many clinically unrecognized diagnoses that affect change in treatment.

METHOD

Patients ≥ 40 years, triaged as high-risk or moderate-to-high risk according to vital signs, were eligible for inclusion. Patients were scanned with a combined ECG-gated and dual energy CT scan of cerebrum, thorax, and abdomen. The impact of the CT scan on patient diagnosis and treatment was examined prospectively by an expert panel.

RESULTS

A total of 100 patients were included in the study, (53% female, mean age 73 years [age range, 43-93]). The scan lead to change in treatment or additional examinations in 37 (37%) patients, of which 24 (24%) were diagnostically significant, change in acute treatment in 11 (11%) cases and previously unrecognized malignant tumors in 10 (10%) cases. The mean size specific radiation dose was 15.9 mSv (± 3.1 mSv).

CONCLUSION

Screening with a multi-rule out CT scan of high-risk patients in an ED is feasible and result in discovery of clinically unrecognized diagnoses and malignant tumors, but at the cost of radiation exposure and downstream examinations. The clinical impact of these findings should be evaluated in a larger randomized cohort.

Reinventing Emergency Department Flow via Healthcare Delivery Science

Healthcare system flow resulting in emergency departments (EDs) crowding is a quality and access problem. This case study examines an overcrowded academic health center ED with increasing patient volumes and limited physical space for expansion. ED capacity and efficiency improved via engineering principles application, addressing patient and staffing flows, and reinventing the delivery model. Using operational data and staff input, patient and staff flow models were created, identifying bottlenecks (points of inefficiency). A new flow model of emergency care delivery, physician-directed queuing, was developed. Expanding upon physicians in triage, providers passively evaluate all patients upon arrival, actively manage patients requiring fewer resources, and direct patients requiring complex resources to further evaluation in ED areas. Sustained over time, ED efficiency improved as measured by near elimination of "left without being seen" patients and waiting times with improvement in door to doctor, patient satisfaction, and total length of stay. All improvements were in the setting on increased patient volume and no increase in physician staffing. Our experience suggests that practical application of healthcare delivery science can be used to improve ED efficiency.

Clinical decision support increases diagnostic yield of computed tomography for suspected pulmonary embolism

OBJECTIVE

Determine effects of evidence-based clinical decision support (CDS) on the use and yield of computed tomographic pulmonary angiography for suspected pulmonary embolism (CTPE) in Emergency Department (ED) patients.

METHODS

This multi-site prospective quality improvement intervention conducted in three urban EDs used a pre/post design. For ED patients aged 18+years with suspected PE, CTPE use and yield were compared 19months pre- and 32months post-implementation of CDS intervention based on the Wells criteria, provided at the time of CTPE order, deployed in April 2012. Primary outcome was the yield (percentage of studies positive for acute PE). Secondary outcome was utilization (number of studies/100 ED visits) of CTPE. Chi-square and statistical process control chart assessed pre- and post-intervention differences. An interrupted time series analysis was also performed.

RESULTS

Of 558,795 patients presenting October 2010-December 2014, 7987 (1.4%) underwent CTPE (mean age 52±17.5years, 66% female, 60.1% black); 34.7% of patients presented pre- and 65.3% post-CDS implementation. Overall CTPE diagnostic yield was 9.8% (779/7987 studies positive for PE). Yield increased a relative 30.8% after CDS implementation (8.1% vs. 10.6%; p=0.0003). There was no statistically significant change in CTPE utilization (1.4% pre- vs. 1.4% post-implementation; p=0.25). A statistical process control chart demonstrated immediate and sustained improvement in CTPE yield post-implementation. Interrupted time series analysis demonstrated the slope of PE findings versus time to be unchanged before and after the intervention (p=0.9). However, there was a trend that the intervention was associated with a 50% increased probability of PE finding (p=0.08), suggesting an immediate rather than gradual change after the intervention.

CONCLUSIONS

Implementing evidence-based CDS in the ED was associated with an immediate, significant and sustained increase in CTPE yield without a measurable decrease in CTPE utilization. Further studies will be needed to assess whether stronger interventions could further improve appropriate use of CTPE.

Emergency Department Holding Orders

BACKGROUND

Holding orders help transition admitted emergency department (ED) patients to hospital beds.

OBJECTIVE

To describe the effect of ED holding orders.

METHODS

We conducted a single-site retrospective study of ward admissions from the ED to the hospital internal medicine (HIM) service over 2 years. Patients were classified based on whether the ED did (group 1) or did not (group 2) write holding orders; group 1 was subdivided into patients sent to the floor with only ED holding orders (group 1A) vs. with subsequent HIM admission orders (group 1B). Outcomes were ED length of stay (LOS), time from decision to admit to ED departure (D→D), transfer to a higher level of care within 6 h (potential undertriage), and discharge from admission ward within 12 h (potential overtriage).

RESULTS

There were 9501 admissions: 6642 in group 1 (2369 in group 1A and 4273 in group 1B) and 2859 in group 2. Reductions in mean LOS between groups (with 95% confidence intervals [CIs] of the differences) were as follows: group 1 vs. 2: 44 min (39-49 min); group 1A vs. 1B, 48 min (43-53 min); group 1B vs. 2: 27 min (22-32 min); group 1A vs. 2: 75 min (69-81 min). Mean D→D was shorter in group 1A than 1B by 43 min (40-45 min). Holding orders were not associated with increases in potential undertriage or overtriage.

CONCLUSIONS

ED holding orders were associated with improved ED throughput, without evidence of undertriage or overtriage. This work supports the use of holding orders as a safe and effective means to improve ED patient flow.

Impact on patient outcome of emergency department length of stay prior to ICU admission

OBJECTIVE

The favorable evolution of critically ill patients is often dependent on time-sensitive care intervention. The timing of transfer to the intensive care unit (ICU) therefore may be an important determinant of outcomes in critically ill patients. The aim of this study was to analyze the impact upon patient outcome of the length of stay in the Emergency Care Department.

DESIGN

A single-center ambispective cohort study was carried out.

SETTING

A general ICU and Emergency Care Department (ED) of a single University Hospital.

PATIENTS

We included 269 patients consecutively transferred to the ICU from the ED over an 18-month period.

INTERVENTIONS

Patients were first grouped into different cohorts based on ED length of stay (LOS), and were then divided into two groups: (a) ED LOS ≤5h and (b) ED LOS >5h.

VARIABLES

Demographic, diagnostic, length of stay and mortality data were compared among the groups.

RESULTS

Median ED LOS was 277min (IQR 129-622). Patients who developed ICU complications had a longer ED LOS compared to those who did not (349min vs. 209min, p<0.01). A total of 129 patients (48%) had ED LOS >5h. The odds ratio of dying for patients with ED LOS >5h was 2.5 (95% CI 1.3-4.7). Age and sepsis diagnosis were the risk factors associated to prolongation of ED length of stay.

CONCLUSIONS

A prolonged ED stay prior to ICU admission is related to the development of time-dependent complications and increased mortality. These findings suggest possible benefit from earlier ICU transfer and the prompt initiation of organ support.

Crowding measures associated with the quality of emergency department care: a systematic review

OBJECTIVES

Despite the substantial body of literature on emergency department (ED) crowding, to the best of our knowledge, there is no agreement on the measure or measures that should be used to quantify crowding. The objective of this systematic review was to identify existing measures of ED crowding that have been linked to quality of care as defined by the Institute of Medicine (IOM) quality domains (safe, effective, patient-centered, efficient, timely, and equitable).

METHODS

Six major bibliographic databases were searched from January 1980 to January 2012, and hand searches were conducted of relevant journals and conference proceedings. Observational studies (cross-sectional, cohort, and case-control), quality improvement studies, quasi-experimental (e.g., before/after) studies, and randomized controlled trials were considered for inclusion. Studies that did not provide measures of ED crowding were excluded. Studies that did not provide quantitative data on the link between crowding measures and quality of care were also excluded. Two independent reviewers assessed study eligibility, completed data extraction, and assessed study quality using the Newcastle-Ottawa Quality Assessment Scale (NOS) for observational studies and a modified version of the NOS for cross-sectional studies.

RESULTS

The search identified 7,413 articles. Thirty-two articles were included in the review: six cross-sectional, one case-control, 23 cohort, and two retrospective reviews of performance improvement data. Methodologic quality was moderate, with weaknesses in the reporting of study design and methodology. Overall, 15 of the crowding measures studied had quantifiable links to quality of care. The three measures most frequently linked to quality of care were the number of patients in the waiting room, ED occupancy (percentage of overall ED beds filled), and the number of admitted patients in the ED awaiting inpatient beds. None of the articles provided data on the link between crowding measures and the IOM domains reflecting equitable and efficient care.

CONCLUSIONS

The results of this review provide data on the association between ED crowding measures and quality of care. Three simple crowding measures have been linked to quality of care in multiple publications.

Emergency department occupancy ratio is associated with increased early mortality

BACKGROUND

To measure emergency department (ED) crowding, the emergency department occupancy ratio (EDOR) was introduced.

OBJECTIVE

Our aim was to determine whether the EDOR is associated with mortality in adult patients who visited the study hospital ED.

METHODS

We reviewed data on all patients who visited the ED of an urban tertiary academic hospital in Korea for 2 consecutive years. The EDOR is defined by the total number of patients in the ED divided by the number of licensed ED beds. We tested the association between the EDOR (quartile) and each outcome using a multivariable logistic regression analysis adjusted for potential confounders: age, sex, emergency medical services transport, transferred case, weekend visit, shift, triage acuity, visit cause of injury, operation, vital signs, intensive care unit or ward admission, and ED length of stay (quartile). The main outcome measures were survival status at discharge and at 1-7 days.

RESULTS

A total of 54,410 adult patients were enrolled. The EDOR ranged from 0.41 to 2.31 and the median was 1.24. On multivariable analyses, in comparison with the lowest (first) quartile, the highest (fourth) quartile of the EDOR was associated with 1-day mortality (adjusted odds ratio [OR] = 1.42; 95% confidence interval [CI] 1.08-1.88), 2-day mortality (adjusted OR = 1.31; 95% CI 1.04-1.67), and 3-day mortality (adjusted OR = 1.27; 95% CI 1.02-1.58). The EDOR was not significantly associated with 4- to 7-day mortalities and overall mortality at discharge.

CONCLUSIONS

The EDOR is associated with increased 1- to 3-day mortality even after controlling for potential confounders.

Overuse of computed tomography pulmonary angiography in the evaluation of patients with suspected pulmonary embolism in the emergency department

BACKGROUND

Clinical decision rules have been developed and validated for the evaluation of patients presenting with suspected pulmonary embolism (PE) to the emergency department (ED).

OBJECTIVES

The objective was to assess the percentage of computed tomographic pulmonary angiography (CT-PA) procedures that could have been avoided by use of the Wells score coupled with D-dimer testing (Wells/D-dimer) or pulmonary embolism rule-out criteria (PERC) in ED patients with suspected PE.

METHODS

The authors conducted a prospective cohort study of adult ED patients undergoing CT-PA for suspected PE. Wells score and PERC were calculated. A research blood sample was obtained for D-dimer testing for subjects who did not undergo testing as part of their ED evaluation. The primary outcome was PE by CT-PA or 90-day follow-up. Secondary outcomes were ED length of stay (LOS) and CT-PA time as defined by time from order to initial radiologist interpretation.

RESULTS

Of 152 suspected PE subjects available for analysis (mean ± SD age = 46.3 ± 15.6 years, 74% female, 59% black or African American, 11.8% diagnosed with PE), 14 (9.2%) met PERC, none of whom were diagnosed with PE. A low-risk Wells score (≤4) was assigned to 110 (72%) subjects, of whom only 38 (35%) underwent clinical D-dimer testing (elevated in 33/38). Of the 72 subjects with low-risk Wells scores who did not have D-dimers performed in the ED, archived research samples were negative in 16 (22%). All 21 subjects with low-risk Wells scores and negative D-dimers were PE-negative. CT-PA time (median = 160 minutes) accounted for more than half of total ED LOS (median = 295 minutes).

CONCLUSIONS

In total, 9.2 and 13.8% of CT-PA procedures could have been avoided by use of PERC and Wells/D-dimer, respectively.

Association of emergency department length of stay with safety-net status

CONTEXT

Performance measures, particularly pay for performance, may have unintended consequences for safety-net institutions caring for disproportionate shares of Medicaid or uninsured patients.

OBJECTIVE

To describe emergency department (ED) compliance with proposed length-of-stay measures for admissions (8 hours or 480 minutes) and discharges, transfers, and observations (4 hours or 240 minutes) by safety-net status.

DESIGN, SETTING, AND PARTICIPANTS

The 2008 National Hospital Ambulatory Medical Care Survey (NHAMCS) ED data were stratified by safety-net status (Centers for Disease Control and Prevention definition) and disposition (admission, discharge, observation, transfer). The 2008 NHAMCS is a national probability sample of 396 hospitals (90.2% unweighted response rate) and 34 134 patient records. Visits were excluded for patients younger than 18 years, missing length-of-stay data or dispositions of missing, other, left against medical advice, or dead on arrival. Median and 90th percentile ED lengths of stay were calculated for each disposition and admission/discharge subcategories (critical care, psychiatric, routine) stratified by safety-net status. Multivariable analyses determined associations with length-of-stay measure compliance.

MAIN OUTCOME MEASURES

Emergency Department length-of-stay measure compliance by disposition and safety-net status.

RESULTS

Of the 72.1% ED visits (N = 24 719) included in the analysis, 42.3% were to safety-net EDs and 57.7% were to non-safety-net EDs. The median length of stay for safety-net was 269 minutes (interquartile range [IQR], 178-397 minutes) for admission vs 281 minutes (IQR, 178-401 minutes) for non-safety-net EDs; 156 minutes (IQR, 95-239 minutes) for discharge vs 148 minutes (IQR, 88-238 minutes); 355 minutes (IQR, 221-675 minutes) for observations vs 298 minutes (IQR, 195-440 minutes); and 235 minutes (IQR, 155-378 minutes) for transfers vs 239 minutes (IQR, 142-368 minutes). Safety-net status was not independently associated with compliance with ED length-of-stay measures; the odds ratio was 0.83 for admissions (95% CI, 0.52-1.34); 1.03 for discharges (95% CI, 0.83-1.27); 1.05 for observations (95% CI, 0.57-1.95), 1.30 for transfers (95% CI, 0.70-2.45]); or subcategories except for psychiatric discharges (1.67, [95% CI, 1.02-2.74]).

CONCLUSION

Compliance with proposed ED length-of-stay measures for admissions, discharges, transfers, and observations did not differ significantly between safety-net and non-safety-net hospitals.

The association between length of emergency department boarding and mortality

OBJECTIVES

Emergency department (ED) boarding has been associated with several negative patient-oriented outcomes, from worse satisfaction to higher inpatient mortality rates. The current study evaluates the association between length of ED boarding and outcomes. The authors expected that prolonged ED boarding of admitted patients would be associated with higher mortality rates and longer hospital lengths of stay (LOS).

METHODS

This was a retrospective cohort study set at a suburban academic ED with an annual ED census of 90,000 visits. Consecutive patients admitted to the hospital from the ED and discharged between October 2005 and September 2008 were included. An electronic medical record (EMR) system was used to extract patient demographics, ED disposition (discharge, admit to floor), ED and hospital LOS, and in-hospital mortality. Boarding was defined as ED LOS 2 hours or more after decision for admission. Descriptive statistics were used to evaluate the association between length of ED boarding and hospital LOS, subsequent transfer to an intensive care unit (ICU), and mortality controlling for comorbidities.

RESULTS

There were 41,256 admissions from the ED. Mortality generally increased with increasing boarding time, from 2.5% in patients boarded less than 2 hours to 4.5% in patients boarding 12 hours or more (p < 0.001). Mean hospital LOS also showed an increase with boarding time (p < 0.001), from 5.6 days (SD ± 11.4 days) for those who stayed in the ED for less than 2 hours to 8.7 days (SD ± 16.3 days) for those who boarded for more than 24 hours. The increases were still apparent after adjustment for comorbid conditions and other factors.

CONCLUSIONS

Hospital mortality and hospital LOS are associated with length of ED boarding.

[Benchmarking in the emergency unit process in 7 hospitals from different autonomous communities]

OBJECTIVE

To identify and to share the results among hospitals regarding the process of attention at the Emergency Unit, and to detect the practices that explain the differences.

MATERIAL AND METHOD

SETTING

7 hospitals of different regions in Spain.

PERIOD OF STUDY

2005-2007. Firstly the comparability criteria were defined assuring the homotecia in the «emergency process». In order to fulfil the study objectives, 11 criteria were selected and every center sent the information of each one. 7 indicators were identified to compare hospitals processes'. Data regarding all the attentions provided during the study period was analyzed, establishing the benchmark among the centers. Finally, a questionnaire was elaborated for the process analysis, considering all the stages of the process, the resources and the procedures used in every stage, to be fulfilled in each hospital.

RESULTS

The homotecia has been verified in the 7 hospitals, with some differences between centers. 7 indicators have been analyzed in the different hospitals, corresponding to 1,526,890 patients attended in the study period. A benchmark has been identified, with the best results in four of seven indicators: % of admissions from urgencies: 8.3%, emergency pressure: 56.14%, emergency length of stay: 2 hs 20min, and % of patients with length stay > 24h: 0.05%. Differences between the stages of the process, resources and procedures used in every stage in the benchmark center have been analyzed.

CONCLUSIONS

A set of indicators to compare Emergency Departments has been identified, letting us establish the benchmark.

Educational excellence in a crowded emergency department: consensus recommendations from the council of emergency medicine residency directors 2010

OBJECTIVE

Emergency Department (ED) crowding is a major public health problem and one that has not been well studied for its effects on education. The objective of this article was to identify best-practice, consensus recommendations to help emergency medicine (EM) residency programs and faculty maintain educational excellence in an era of ED crowding.

METHODS

A geographically diverse group of 37 clinician-educator leaders in EM convened at the 2010 Council of Emergency Medicine Residency Directors Academic Assembly. The participants discussed innovative ideas and solutions to address the many educational challenges that ED crowding poses.

RESULTS

To cope with crowding, the consensus group identified 3 educational domains, focusing on the educator, the learner, and the institutional system. Core subthemes included optimizing teaching opportunities, providing alternative teaching approaches, and redefining what faculty and learners traditionally think of as teaching. An ED rotation provides ample opportunities for teaching not only about patient care and medical knowledge but also other Accreditation Council for Graduate Medical Education competencies, such as interpersonal and communication skills, professionalism, and system-based practice.

CONCLUSIONS

Crowding in EDs poses educational challenges, but with some creativity, flexibility, and desire to make the most of a challenging situation, educational excellence is an achievable goal.

Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada

OBJECTIVE

To determine whether patients who are not admitted to hospital after attending an emergency department during shifts with long waiting times are at risk for adverse events.

DESIGN

Population based retrospective cohort study using health administrative databases. Setting High volume emergency departments in Ontario, Canada, fiscal years 2003-7.

PARTICIPANTS

All emergency department patients who were not admitted (seen and discharged; left without being seen).

OUTCOME MEASURES

Risk of adverse events (admission to hospital or death within seven days) adjusted for important characteristics of patients, shift, and hospital.

RESULTS

13,934,542 patients were seen and discharged and 617,011 left without being seen. The risk of adverse events increased with the mean length of stay of similar patients in the same shift in the emergency department. For mean length of stay ≥ 6 v <1 hour the adjusted odds ratio (95% confidence interval) was 1.79 (1.24 to 2.59) for death and 1.95 (1.79 to 2.13) for admission in high acuity patients and 1.71 (1.25 to 2.35) for death and 1.66 (1.56 to 1.76) for admission in low acuity patients). Leaving without being seen was not associated with an increase in adverse events at the level of the patient or by annual rates of the hospital.

CONCLUSIONS

Presenting to an emergency department during shifts with longer waiting times, reflected in longer mean length of stay, is associated with a greater risk in the short term of death and admission to hospital in patients who are well enough to leave the department. Patients who leave without being seen are not at higher risk of short term adverse events.

The effect of emergency department crowding on length of stay and medication treatment times in discharged patients with acute asthma

OBJECTIVES

This study sought to determine if emergency department (ED) crowding was associated with longer ED length of stay (LOS) and time to ordering medications (nebulizers and steroids) in patients treated and discharged with acute asthma and to study how delays in ordering may affect the relationship between ED crowding and ED LOS.

METHODS

A retrospective cohort study was performed in adult ED patients aged 18 years and older with a primary International Classification of Diseases, 9th Revision (ICD-9), diagnosis of asthma who were treated and discharged from two EDs from January 1, 2007, to January 1, 2009. Four validated measures of ED crowding (ED occupancy, waiting patients, admitted patients, and patient-hours) were assigned at the time of triage. The associations between the level of ED crowding and overall LOS and time to treatment orders were tested by analyzing trends across crowding quartiles, testing differences between the highest and lowest quartiles using Hodges-Lehmann distances, and using relative risk (RR) regression for multivariable analysis.

RESULTS

A total of 1,716 patients were discharged with asthma over the study period (932 at the academic site and 734 at the community site). LOS was longer at the academic site than the community site for asthma patients by 90 minutes (95% confidence interval [CI] = 79 to 101 minutes). All four measures of ED crowding were associated with longer LOS and time to treatment order at both sites (p < 0.001). At the highest level of ED occupancy, patients spent 75 minutes (95% CI = 58 to 93 minutes) longer in the ED compared to the lowest quartile of ED occupancy. In addition, comparing the highest and lowest quartiles of ED occupancy, time to nebulizer order was 6 minutes longer (95% CI = 1 to 13 minutes), and time to steroid order was 16 minutes longer (95% CI = 0 to 38 minutes). In the multivariable analysis, the association between ED crowding and LOS remained significant. Delays in nebulizer and steroid orders explained some, but not all, of the relationship between ED crowding and ED LOS.

CONCLUSIONS

Emergency department crowding is associated with longer ED LOS (by more than 1 hour) in patients who ultimately get discharged with asthma flares. Some but not all of longer LOS during crowded times is explained by delays in ordering asthma medications.