The Effect of Emergency Department Crowding on Clinically Oriented Outcomes

Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY, USA.
Academic Emergency Medicine (Impact Factor: 2.01). 12/2008; 16(1):1-10. DOI: 10.1111/j.1553-2712.2008.00295.x
Source: PubMed


An Institute of Medicine (IOM) report defines six domains of quality of care: safety, patient-centeredness, timeliness, efficiency, effectiveness, and equity. The effect of emergency department (ED) crowding on these domains of quality has not been comprehensively evaluated.
The objective was to review the medical literature addressing the effects of ED crowding on clinically oriented outcomes (COOs).
We reviewed the English-language literature for the years 1989-2007 for case series, cohort studies, and clinical trials addressing crowding's effects on COOs. Keywords searched included "ED crowding,"ED overcrowding,"mortality,"time to treatment,"patient satisfaction,"quality of care," and others.
A total of 369 articles were identified, of which 41 were kept for inclusion. Study quality was modest; most articles reflected observational work performed at a single institution. There were no randomized controlled trials. ED crowding is associated with an increased risk of in-hospital mortality, longer times to treatment for patients with pneumonia or acute pain, and a higher probability of leaving the ED against medical advice or without being seen. Crowding is not associated with delays in reperfusion for patients with ST-elevation myocardial infarction. Insufficient data were available to draw conclusions on crowding's effects on patient satisfaction and other quality endpoints.
A growing body of data suggests that ED crowding is associated both with objective clinical endpoints, such as mortality, as well as clinically important processes of care, such as time to treatment for patients with time-sensitive conditions such as pneumonia. At least two domains of quality of care, safety and timeliness, are compromised by ED crowding.

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    • "At the same time there has been an increase in demand for ED services with an insufficient supply of resources, resulting in the growing crisis of crowding [22, 23]. ED crowding has reached a “breaking point,” which greatly threatens the provision of safe and efficient care [21, 24, 25]. "
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    ABSTRACT: Study Objectives. In response to the 2010 New York State HIV testing law, we sought to understand the contextual factors that influence HIV testing rates in the emergency department (ED). Methods. We analyzed electronic health record logs from 97,655 patients seen in three EDs in New York City. We used logistic regression to assess whether time of day, day of the week, and season significantly affected HIV testing rates. Results. During our study period, 97,655 patients were evaluated and offered an HIV test. Of these, 7,763 (7.9%) agreed to be tested. Patients arriving between 6 a.m. and 7:59 p.m. were significantly (P < 0.001) more likely to be tested for HIV, followed by patients arriving between 8:00 p.m. and 9:59 p.m. (P < 0.01) and followed by patients arriving between 5-5:59 a.m. and 10-10:59 p.m. (P < 0.05) compared to patients arriving at midnight. Seasonal variation was also observed, where patients seen in July, August, and September (P < 0.001) were more likely to agree to be tested for HIV compared to patients seen in January, while patients seen in April and May (P < 0.001) were less likely to agree to be tested for HIV. Conclusion. Time of day and season affect HIV testing rates in the ED, along with other factors such as patient acuity and completion of other blood work during the ED visit. These findings provide useful information for improving the implementation of an HIV testing program in the ED.
    09/2014; 2014:575130. DOI:10.1155/2014/575130
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    • "Crowding in emergency departments (EDs) nationally and worldwide has impacted the quality of care.1 Increases in patient mortality, medication errors, pain, length of hospital stay, and other deleterious effects have been documented.2 "
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    ABSTRACT: We report the case of a 32-year-old male recently diagnosed with type 2 diabetes treated at an urban university emergency department (ED) crowded to 250% over capacity. His initial symptoms of shortness of breath and feeling ill for several days were evaluated with chest radiograph, electrocardiogram (EKG), and laboratory studies, which suggested mild diabetic ketoacidosis. His medical care in the ED was conducted in a crowded hallway. After correction of his metabolic abnormalities he felt improved and was discharged with arrangements made for outpatient follow-up. Two days later he returned in cardiac arrest, and resuscitation efforts failed. The autopsy was significant for multiple acute and chronic pulmonary emboli but no coronary artery disease. The hospital settled the case for $1 million and allocated major responsibility to the treating emergency physician (EP). As a result the state medical board named the EP in a disciplinary action, claiming negligence because the EKG had not been personally interpreted by that physician. A formal hearing was conducted with the EP's medical license placed in jeopardy. This case illustrates the risk to EPs who treat patients in crowded hallways, where it is difficult to provide the highest level of care. This case also demonstrates the failure of hospital administration to accept responsibility and provide resources to the ED to ensure patient safety.
    The western journal of emergency medicine 03/2014; 15(2):137-41. DOI:10.5811/westjem.2013.11.18645
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    • "Emergency department (ED) patient volume has continued to grow yearly worldwide [1]. This trend has caused many of the same challenges, namely ED overcrowding, compromised patient care, decreased patient satisfaction, and shortages of ED and hospital personnel, regardless of location [2,3]. Although many of these issues lack an obvious or feasible solution, the observation unit (OU) has been shown to be among the most promising tools to address many of these problems [4-8]. "
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    ABSTRACT: To improve efficiency, emergency departments (EDs) use dedicated observation units (OUs) to manage patients who are unable to be discharged home, yet do not clearly require inpatient hospitalization. However, operational metrics and their ideal targets have not been created for this setting and patient population. Variation in these metrics across different countries has not previously been reported. This study aims to define and compare key operational characteristics between three ED OUs in the United States (US) and three ED OUs in Asia. This is a descriptive study of six tertiary-care hospitals, all of which are level 1 trauma centers and have OUs managed by ED staff. We collected data via various methods, including a standardized survey, direct observation, and interviews with unit leadership, and compared these data across continents. We define multiple key operational characteristics to compare between sites, including OU length of stay (LOS), OU discharge rate, and bed turnover rate. OU LOS in the US and Asian sites averaged 12.9 hours (95% CI, 8.3 to 17.5) and 20.5 hours (95% CI, -49.4 to 90.4), respectively (P = 0.39). OU discharge rates in the US and Asia averaged 84.3% (95% CI, 81.5 to 87.2) and 88.7% (95% CI, 81.5 to 95.8), respectively (P = 0.11), and the bed turnover rates in the US and Asian sites averaged 1.6 patients/bed/day (95% CI, -0.1 to 3.3) and 0.9 patient/bed/day (95% CI, -0.6 to 2.4), respectively (P = 0.27). Prior research has shown that the OU is a resource that can mitigate many of problems in the ED and hospital, while simultaneously improving patient care and satisfaction. We describe key operational characteristics that are relevant to all OUs, regardless of geography or healthcare system to monitor and maximize efficiency. Although measures of LOS and bed turnover varied widely between US and Asian sites, we did not find a statistically significant difference. Use of these metrics may enable hospitals to establish or revise an ED OU and reduce OU LOS, increase bed turnover, and discharge rates while simultaneously improving patient satisfaction and quality of care.
    International Journal of Emergency Medicine 02/2014; 7(1):6. DOI:10.1186/1865-1380-7-6
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