30 Association of Emergency Department and Hospital Operation Characteristics on Elopements and Length of Stay

Indiana University-Purdue University Indianapolis, Indianapolis, Indiana, United States
Journal of Emergency Medicine (Impact Factor: 0.97). 01/2014; 60(4). DOI: 10.1016/j.jemermed.2013.08.133
Source: PubMed


As the Centers for Medicare & Medicaid Services (CMS) core measures in 2013 compare Emergency Department (ED) treatment time intervals, it is important to identify ED and hospital characteristics associated with these metrics to facilitate accurate comparisons.
The objective of this study is to assess differences in operational metrics by ED and hospital characteristics. ED-level characteristics included annual ED volume, percentage of patients admitted, percentage of patients presenting by ambulance, and percentage of pediatric patients. Hospital-level characteristics included teaching hospital status, trauma center status, hospital ownership (nonprofit or for-profit), inpatient bed capacity, critical access status, inpatient bed occupancy, and rural vs. urban location area.
Data from the ED Benchmarking Alliance from 2004 to 2009 were merged with the American Hospital Association's Annual Survey Database to include hospital characteristics that may impact ED throughput. Overall median length of stay (LOS) and left before treatment is complete (LBTC) were the primary outcome variables, and a linear mixed model was used to assess the association between outcome variables and ED and hospital characteristics, while accounting for correlations among multiple observations within each hospital. All data were at the hospital level on a yearly basis.
There were 445 EDs included in the analysis, from 2004 to 2009, with 850 observations over 6 years. Higher-volume EDs were associated with higher rates of LBTC and LOS. For-profit hospitals had lower LBTC and LOS. Higher inpatient bed occupancies were associated with a higher LOS. Increasing admission percentages were positively associated with overall LOS for EDs, but not with rates of LBTC.
Higher-volume EDs are associated with higher LBTC and LOS, and for-profit hospitals appear more favorably in these metrics compared with their nonprofit counterparts. It is important to appreciate that hospitals have different baselines for performance that may be more tied to volume and capacity, and less to quality of care.

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    • "Welch et al used 2009 data from the Emergency Department Benchmarking Alliance (EDBA) [6] to demonstrate a direct association between ED volume and acuity with LBTC, door-to-physician times, and length of stay in the ED [7]. Handel et al noted a similar relationship [8]. Implementation of the Affordable Care Act appears to have increased ED volumes [9]; more patients now have insurance coverage, but they do not have adequate access to primary care [10]. "
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    ABSTRACT: Study objective: The percentage of patients leaving before treatment is completed (LBTC) is an important indicator of emergency department performance. The objective of this study is to identify characteristics of hospital operations that correlate with LBTC rates. Methods: The Emergency Department Benchmarking Alliance 2012 and 2013 cross-sectional national data sets were analyzed using multiple regression and k-means clustering. Significant operational variables affecting LBTC including annual patient volume, percentage of high-acuity patients, percentage of patients admitted to the hospital, number of beds, academic status, waiting times to see a physician, length of stay (LOS), registered nurse (RN) staffing, and physician staffing were identified. LBTC was regressed onto these variables. Because of the strong correlation between waiting times measured as door to first provider (DTFP), we regressed DTFP onto the remaining predictors. Cluster analysis was applied to the data sets to further analyze the impact of individual predictors on LBTC and DTFP. Results: LOS and the time from DTFP were both strongly associated with LBTC rate (P<.001). Patient volume is not significantly associated with LBTC rate (P=.16). Cluster analysis demonstrates that physician and RN staffing ratios correlate with shorter DTFP and lower LBTC. Conclusion: Volume is not the main driver of LBTC. DTFP and LOS are much more strongly associated. We show that operational factors including LOS and physician and RN staffing decisions, factors under the control of hospital and physician executives, correlate with waiting time and, thus, in determining the LBTC rate.
    Full-text · Article · Oct 2015 · The American journal of emergency medicine
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    ABSTRACT: The Centers for Medicare & Medicaid Services (CMS) recently published emergency department (ED) timeliness measures. These data show substantial variation in hospital performance and suggest the need for process improvement initiatives. However, the CMS measures are not risk adjusted and may provide misleading information about hospital performance and variation. We hypothesize that substantial hospital-level variation will persist after risk adjustment. This cross-sectional study included hospitals that participated in the Emergency Department Benchmarking Alliance and CMS ED measure reporting in 2012. Outcomes included the CMS measures corresponding to median annual boarding time, length of stay of admitted patients, length of stay of discharged patients, and waiting time of discharged patients. Covariates included hospital structural characteristics and case-mix information from the American Hospital Association Survey, CMS cost reports, and the Emergency Department Benchmarking Alliance. We used a γ regression with a log link to model the skewed outcomes. We used indirect standardization to create risk-adjusted measures. We defined "substantial" variation as coefficient of variation greater than 0.15. The study cohort included 723 hospitals. Risk-adjusted performance on the CMS measures varied substantially across hospitals, with coefficient of variation greater than 0.15 for all measures. Ratios between the 10th and 90th percentiles of performance ranged from 1.5-fold for length of stay of discharged patients to 3-fold for waiting time of discharged patients. Policy-relevant variations in publicly reported CMS ED timeliness measures persist after risk adjustment for nonmodifiable hospital and case-mix characteristics. Future "positive deviance" studies should identify modifiable process measures associated with high performance. Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
    No preview · Article · Jun 2015 · Annals of emergency medicine