Comparison of methods for measuring crowding and its effects on length of stay in the emergency department

Emergency department overcrowding and its associated factors at HARME medical emergency center in Eastern Ethiopia

Introduction

Emergency department (ED) overcrowding has become a significant concern as it can lead to compromised patient care in emergency settings. Various tools have been used to evaluate overcrowding in ED. However, there is a lack of data regarding this issue in resource-limited countries, including Ethiopia. This study aimed to validate NEDOCS, assess level of ED overcrowding and identify associated factors at HARME Medical Emergency Center, located in Hiwot Fana Comprehensive Specialized Hospital, Harar, Ethiopia.

Methods

A cross-sectional study was conducted at the HARME Medical Emergency Center, Hiwot Fana Comprehensive Specialized Hospital, involving a total of 899 patients during 120 sampling intervals. The area under the receiver operating characteristic curves (AUC) was calculated to evaluate the agreement between objective and subjective assessments of ED overcrowding. A multivariable logistic regression analysis was employed to identify factors associated with ED overcrowding and statistically significant association was declared using 95 % confidence level and a p-value < 0.05.

Results

The interrater agreement showed a strong correlation with a Cohen's kappa (κ) of 0.80. The National Emergency Department Overcrowding Study Score demonstrated a strong association with subjective assessments from residents and case team nurses, with an AUC of 0.81 and 0.79, respectively. According to residents' perceptions, ED were considered overcrowded 65.8 % of the time. Factors significantly associated with ED overcrowding included waiting time for triage (AOR: 2.24; 95 % CI: 1.54-3.27), working time (AOR: 2.23; 95 % CI: 1.52-3.26), length of stay (AOR: 2.40; 95 % CI: 1.27-4.54), saturation level (AOR: 2.35; 95 % CI: 1.31-4.20), chronic illness (AOR: 2.19; 95 % CI: 1.37-3.53), and abnormal pulse rate (AOR: 1.52; 95 % CI: 1.06-2.16).

Conclusion

The study revealed that ED were overcrowded approximately two-thirds of the time.

Emergency department crowding and mortality: an observational multicenter study in Sweden

Background

Emergency department (ED) crowding is a serious problem worldwide causing decreased quality of care. It is reasonable to assume that the negative effects of crowding are at least partially due to high staff workload, but previous crowding metrics based on high workload have not been generalisable to Swedish EDs and have not been associated with increased mortality, in contrast to, e.g., occupancy rate. We recently derived and validated the modified Skåne Emergency Department Assessment of Patient Load model (mSEAL) that measures crowding based on staff workload in Swedish EDs, but its ability to identify situations with increased mortality is unclear. In this study, we aimed to investigate the association between ED crowding measured by mSEAL model, or occupancy rate, and mortality.

Methods

All ED patients from 2017-01-01 to 2017-06-30 from two regional healthcare systems (Skåne and Östergötland Counties with a combined population of approximately 1.8 million) in Sweden were included. Exposure was ED- and hour-adjusted mSEAL or occupancy rate. Primary outcome was mortality within 7 days of ED arrival, with one-day and 30-day mortality as secondary outcomes. We used Cox regression hazard ratio (HR) adjusted for age, sex, arrival by ambulance, hospital admission and chief complaint.

Results

We included a total of 122,893 patients with 168,900 visits to the six participating EDs. Arriving at an hour with a mSEAL score above the 95th percentile for that ED and hour of day was associated with an non-significant HR for death at 7 days of 1.04 (95% CI 0.96-1.13). For one- and 30-day mortality the HR was non-significant at 1.03 (95% CI 0.9-1.18) and 1.03 (95% CI 0.97-1.09). Similarly, occupancy rate above the 95th percentile with a HR of 1.04 (95% CI 0.9-1.19), 1.03 (95%CI 0.95-1.13) and 1.04 (95% CI 0.98-1.11) for one-, 7- and 30-day mortality, respectively.

Conclusion

In this multicenter study in Sweden, ED crowding measured by mSEAL or occupancy rate was not associated with a significant increase in short-term mortality.

The effect of increased emergency department demand on throughput times and disposition status for pediatric psychiatric patients

OBJECTIVES

Emergency department (ED) crowding has been shown to increase throughput measures of length of stay (LOS), wait time, and boarding time. Psychiatric utilization of the ED has increased, particularly among younger patients. This investigation quantifies the effect of ED demand on throughput times and discharge disposition for pediatric psychiatric patients in the ED.

METHODS

Using electronic medical record data from 1,151,396 ED visits in eight North Carolina EDs from January 1, 2018, through December 31, 2020, we identified 14,092 pediatric psychiatric visits. Measures of ED daily demand rates included overall occupancy as well as daily proportion of non-psychiatric pediatric patients, adult psychiatric patients, and pediatric psychiatric patients. Controlling for patient-level factors such as age, sex, race, insurance, and triage acuity, we used linear regression to predict throughput times and logistic regression to predict disposition status. We estimated effects of ED demand by academic versus community hospital status due to ED and inpatient resource differences.

RESULTS

Most ED demand measures had insignificant or only very small associations with throughput measures for pediatric psychiatric patients. Notable exceptions were that a one percentage point increase in the proportion of non-psychiatric pediatric ED visits increased boarding times at community sites by 1.06 hours (95% CI: 0.20-1.92), while a one percentage point increase in the proportion of pediatric psychiatric ED visits increased LOS by 3.64 hours (95% CI: 2.04-5.23) at the academic site. We found that ED demand had a minimal effect on disposition status, with small increases in demand rates favoring <1 percentage point increases in the likelihood of discharge. Instead, patient-level factors played a much stronger role in predicting discharge disposition.

CONCLUSIONS

ED demand has a meaningful effect on throughput times, but a minimal effect on disposition status. Further research is needed to validate these findings across other state and healthcare systems.

Bed-to-Bed Transfer Program Among Patients Who Need Hospitalization in a Crowded Emergency Department in Taiwan

BACKGROUND

Emergency department (ED) crowding is a universal issue. In Taiwan, patients with common medical problems prefer to visit ED of medical centers, resulting in overcrowding. Thus, a bed-to-bed transfer program has been implemented since 2014. However, there was few studies that compared clinical outcomes among patients who choose to stay in medical centers to those being transferred to regional hospitals. The aim of this study was to explore the transfer rate, delineate the factors related to patient transfer, and clarify the influence upon the program outcomes.

METHODS

A retrospective cohort study was conducted using demographic and clinical disease factors from the patient electronic referral system, electronic medical records (EMRs) of a medical center in Taipei, and response to referrals from regional hospitals. The study included adult patients who were assessed as appropriate for transfer in 2016. We analyzed the outcomes (length of stay and mortality rate) between the referrals were accepted and refused using propensity score matching.

RESULTS

Of the 1759 patients eligible for transfer to regional hospitals, 420 patients (24%) accepted the referral. Medical records were obtained from the regional hospitals for 283 patients (67%). After propensity score matching, the results showed that interhospital transfer resulted in similar median total length of stay (8.7 days in the medical center vs 7.9 days in regional hospitals; P=.245). In-hospital mortality was low for both groups (3.1% in the medical center vs 1.3% in regional hospitals; P=.344).

CONCLUSION

Transfer from an overcrowded ED in a medical center to regional hospitals in eligible patients results in non-significant outcome of total length of stay. With the caveat of an underpowered sample, we did not find statistically significant differences in in-hospital mortality. This healthcare delivery model may be used in other cities facing similar problems of ED overcrowding.

The association between length of stay in the emergency department and short-term mortality

The detrimental effects of increased length of stay at the emergency department (ED-LOS) for patient outcome have been sparsely studied in the Swedish setting. Our aim was to further explore the association between ED-LOS and short-term mortality in patients admitted to the EDs of two large University hospitals in Sweden. All adult patients (> 18 years) visiting the ED at the Karolinska University Hospital, Sweden, from 1/1/2010 to 1/1/2015 (n = 639,385) were retrospectively included. Logistic regression analysis was used to determine association between ED-LOS and 7- and 30-day mortality rates. All patients were triaged according to the RETTS-A into different levels of medical urgency and subsequently separated into five quintiles of ED-LOS. Mortality rate was highest in highest triage priority level (7-day mortality 5.24%, and 30-day mortality 9.44%), and decreased by lower triage priority group. For patients with triage priority levels 2-4, prolonged ED-LOS was associated with increased mortality, especially for lowest priority level, OR for priority level 4 and highest quintile of ED-LOS 30-day mortality 1.49 (CI 95% 1.20-1.85). For patients with highest triage priority level the opposite was at hand, with decreasing mortality risk with increasing quintile of ED-LOS for 7-day mortality, and lower mortality for the two highest quintile of ED-LOS for 30-day mortality. In patients not admitted to in-hospital care higher ED-LOS was associated with higher mortality. Our data suggest that increased ED-LOS could be associated with slightly increased short-term mortality in patients with lower clinical urgency and dismissed from the ED.

Universal SARS-CoV-2 Testing of Emergency Department Admissions Increases Emergency Department Length of Stay

Study objective

Our institution experienced a change in SARS-CoV-2 testing policy as well as substantial changes in local COVID-19 prevalence, allowing for a unique examination of the relationship between SARS-CoV-2 testing and emergency department (ED) length of stay.

Methods

This was an observational interrupted time series of all patients admitted to an academic health system between March 15, 2020, and September 30, 2020. Given testing limitations from March 15 to April 24, all patients receiving SARS-CoV-2 tests were symptomatic. On April 24, testing was expanded to all ED admissions. The primary and secondary outcomes were ED length of stay and number needed to test to obtain a positive, respectively.

Results

A total of 70,856 patients were cared for in the EDs during the 7-month period. The testing change increased admission length of stay by 1.89 hours (95% confidence interval 1.39 to 2.38). The number needed to test was 2.5 patients and was highest yield on April 1, 2020, when the state positivity rate was 39.7%; however, the number needed to test exceeded 170 patients by Sept 1, 2020, at which point the state positivity rate was 0.5%.

Conclusion

Although universal SARS-CoV-2 testing of ED admissions may meaningfully support mitigation and containment efforts, the clinical cost of testing all admissions amid low community positivity is notable. In our system, universal ED SARS-CoV-2 testing was associated with a 24% increase in admission length of stay alongside the detection of only 1 positive case every other day. Given the known harms and risks of ED boarding and crowding, solutions must be developed to support regular operational flow while balancing infection prevention needs.

Emergency department crowding and mortality for patients presenting to emergency departments in New Zealand

OBJECTIVE

The association between ED crowding and mortality has been established internationally, but not in New Zealand. The aim was to determine which measures of crowding were associated with mortality for new patients presenting to New Zealand EDs. The primary outcome was mortality for patients within 7 days of arrival in the ED.

METHODS

This was a retrospective cohort study, using administrative data from 2006 to 2012. The crowding conditions at the time of presentation of each patient were recreated. Multivariable Cox proportional hazard modelling was used to determine the probability of death within 7 days of the presentation to ED. Each crowding measure was added independently to the optimum mortality model to determine how each crowding metric influenced the model.

RESULTS

Twenty-five of 28 (89%) eligible acute hospitals in New Zealand were included, with 5 793 767 ED visits by 2 214 865 individuals. Seven-day mortality was higher for patients arriving at times when there was more than 10% hospital access block (hazard ratio [HR] 1.10, 95% confidence interval [CI] 1.05, 1.17) or non-compliance with the 4-h emergency access target (HR 1.07, 95% CI 1.01, 1.12). ED occupancy did not influence the model importantly, while the number of arrivals in the previous 6 h was associated with lower mortality (HR 0.90, 95% CI 0.84, 0.97).

CONCLUSION

Access block had the strongest association with 7-day mortality. That ED occupancy and the number of arrivals were not associated with increased mortality suggests that system issues related to long ED stays may be most important in the link between ED crowding and mortality.

Long emergency department length of stay: A concept analysis

INTRODUCTION

Emergency Department (ED) Length of stay (LOS) has been associated with poor patient outcomes, which has led to the implementation of time targets designed to keep EDLOS below a specific limit. The cut-offs defining long EDLOS varies across settings and seem to be arbitrarily chosen. This study aimed to clarify the meaning of long EDLOS.

METHODS

A concept analysis using the Walker and Avant approach was conducted. It included a literature search aiming to identify all uses of the concept, resulting in a set of defining attributes and a way of measuring the concept empirically.

RESULTS

Long EDLOS was primarily used as proxy for other phenomena, e.g. boarding or crowding. The definitions had cut-offs ranging between 4 and 48 h. The attributes defining long EDLOS was waiting, a crowded ED environment and an inefficient organization.

DISCUSSION

Time targets are probably more suitable when directed towards and tailored for specific sub-groups of the ED population.

Patient length of stay, patient readmission rates and the provision of professional interpreting services in healthcare in Australia

Linguistic and ethnic diversity is a feature of patient profiles at almost all public healthcare facilities in urban areas in Australia. Patients with limited proficiency in the socially dominant language - in this case Limited English proficiency (LEP) patients - commonly form a significant patient group in public healthcare settings. Communication barriers that exist between patients and healthcare professionals necessitate the provision of translation and interpreting (T&I) services. This study presents longitudinal data from Melbourne, Australia, on the provision of (T&I) services together with patient length of stay (LOS) and patient readmission rates over a 10-year period at a large, public healthcare provider. Patient LOS and patient readmission rates are key metrics for effective diagnosis and treatment of patients and commonly used to measure the performance of various aspects of healthcare provision. The augmentation of T&I services within a general policy of patient-centred care is shown to accompany decreased LOS and lower readmission rates for LEP patients.

[Emergency overcrowding and hospital organization: Causes and solutions]

Emergency Department (ED) overcrowding is a silent killer. Thus, several studies in different countries have described an increase in mortality, a decrease in the quality of care and prolonged hospital stays associated with ED overcrowding. Causes are multiple: input and in particular lack of access to lab test and imaging for general practitioners, throughput and unnecessary or time-consuming tasks, and output, in particular the availability of hospital beds for unscheduled patients. The main cause of overcrowding is waiting time for available beds in hospital wards, also known as boarding. Solutions to resolve the boarding problem are mostly organisational and require the cooperation of all department and administrative levels through efficient bed management. Elderly and polypathological patients wait longer time in ED. Internal Medicine, is the ideal specialty for these complex patients who require time for observation and evaluation. A strong partnership between the ED and the internal medicine department could help to reduce ED overcrowding by improving care pathways.

Patient Characteristics and Clinical Process Predictors of Patients Leaving Without Being Seen from the Emergency Department

INTRODUCTION

Delays in patient flow in the emergency department (ED) result in patients leaving without being seen (LWBS). This compromises patient experience and quality of care. Our primary goal was to develop a predictive model by evaluating associations between patients LWBS and ED process measures and patient characteristics.

METHODS

This was a cross-sectional study in a 95,000 annual visit adult ED comparing patients LWBS, with controls. Data were drawn from four seasonally adjusted four-week periods (30,679 total visits). Process measures included 1) arrivals per hour; 2) "door-to-provider" time; and the numbers of 3) patients in the waiting room; 4) boarding ED patients waiting for an inpatient bed; 5) providers and nurses (RN); and 6) patients per RN. Patient characteristics collected included 1) age; 2) gender; 3) race/ethnicity; 4) arrival mode (walk-in or via emergency medical services [EMS]); and 5) acuity based on Emergency Severity Index (ESI). Univariable analyses included t-tests and Pearson's chi-square tests. We split the data randomly into derivation and validation cohorts. We used backward selection to develop the final derivation model, and factors with a p-value ≤ 0.05 were retained. Estimates were applied to the validation cohort and measures of discrimination (receiver operating characteristic) and model fit were assessed.

RESULTS

In the final model, the odds of LWBS increased with the number of patients in the waiting room (odds ratio [OR] 1.05; 95% confidence interval [CI], 1.03 to 1.06); number of boarding patients (OR 1.02; 95% CI, 1.01 to 1.03); arrival rate (OR 1.04; 95% CI, 1.02 to 1.05) and longer "door-to-provider" times (test of linear trend in the adjusted OR was p = 0.002). Patient characteristics associated with LWBS included younger age (OR 0.98; 95% CI, 0.98 to 0.99), and lower acuity (higher ESI category) (OR 2.01; 95% CI, 1.84 to 2.20). Arrival by EMS was inversely associated with LWBS (OR 0.29; 0.23 to 0.36). The area under the curve for the final model in the validation cohort was 0.85 (95% CI, 0.84 to 0.86). There was good agreement between the observed and predicted risk.

CONCLUSION

Arrival rate, "door-to-provider time," and the numbers of patients in the waiting room and ED boarders are all associated with patients LWBS.

Influence of Overcrowding in the Emergency Department on Return Visit within 72 Hours

This study was conducted to determine whether overcrowding in the emergency department (ED) affects the occurrence of a return visit (RV) within 72 h. The crowding indicator of index visit was the average number of total patients, patients under observation, and boarding patients during the first 1 and 4 h from ED arrival time and the last 1 h before ED departure. Logistic regression analysis was conducted to determine whether each indicator affects the occurrence of RV and post-RV admission. Of the 87,360 discharged patients, 3743 (4.3%) returned to the ED within 72 h. Of the crowding indicators pertaining to total patients, the last 1 h significantly affected decrease in RV (p = 0.0046). Boarding patients were found to increase RV occurrence during the first 1 h (p = 0.0146) and 4 h (p = 0.0326). Crowding indicators that increased the likelihood of admission post-RV were total number of patients during the first 1 h (p = 0.0166) and 4 h (p = 0.0335) and evaluating patients during the first 1 h (p = 0.0059). Overcrowding in the ED increased the incidence of RV and likelihood of post-RV admission. However, overcrowding at the time of ED departure was related to reduced RV.

Decision Support for the Optimization of Provider Staffing for Hospital Emergency Departments with a Queue-Based Approach

Deployment or distribution of valuable medical resources has emerged as an increasing challenge to hospital administrators and health policy makers. The hospital emergency department (HED) census and workload can be highly variable. Improvement of emergency services is an important stage in the development of the healthcare system and research on the optimal deployment of medical resources appears to be an important issue for HED long-term management. HED performance, in terms of patient flow and available resources, can be studied using the queue-based approach. The kernel point of this research is to approach the optimal cost on logistics using queuing theory. To model the proposed approach for a qualitative profile, a generic HED system is mapped into the M/M/R/N queue-based model, which assumes an R-server queuing system with Poisson arrivals, exponentially distributed service times and a system capacity of N. A comprehensive quantitative mathematical analysis on the cost pattern was done, while relevant simulations were also conducted to validate the proposed optimization model. The design illustration is presented in this paper to demonstrate the application scenario in a HED platform. Hence, the proposed approach provides a feasibly cost-oriented decision support framework to adapt a HED management requirement.

Emergency Radiology: Current Challenges and Preparing for Continued Growth

The escalation of imaging volumes in the emergency department and intensifying demands for rapid radiology results have increased the demand for emergency radiology. The provision of emergency radiology is essential for nearly all radiology practices, from the smallest to the largest. As our radiology specialty responds to the challenge posed by the triple threat of providing 24-7 coverage, high imaging volumes, and rapid turnaround time, various questions regarding emergency radiology have emerged, including its definition and scope, unique operational demands, quality and safety concerns, impact on physician well-being, and future directions. This article reviews the current challenges confronting the subspecialty of emergency radiology and offers insights into preparing for continued growth.

Risk Factors for Prolonged Length of Stay of Older Patients in an Academic Emergency Department: A Retrospective Cohort Study

Emergency departments (EDs) are challenged with a growing population of older patients. These patients are at risk for a prolonged length of stay (LOS) at the ED and face more complications and poorer clinical outcomes. We aimed to identify risk factors for a prolonged LOS of older patients at the ED. For this retrospective clinical database study, we analyzed medical records of 2000 patients ≥70 years old presenting at the ED of a large level I trauma center in the Netherlands. LOS above the 75^th percentile of LOS at our ED, 293 minutes, was considered prolonged. After bivariate analysis, we identified associations between LOS and patient, organizational, and clinical factors. Associations with a p < 0.05 were inserted in multivariable logistic regression models. We analyzed 1048 men (52%) and 952 women (48%) with a mean age of 78 ± 6.2 years. Risk factors for prolonged LOS of older patients at the ED were follows: higher number (more than one) of consultations (OR [odds ratio] 2.4, CI [confidence interval] 2.0-2.91), or diagnostic interventions (OR 1.5, CI 1.4-1.7); presenting complaints of a neurological (OR 2.2, CI 1.0-4.5) or internal medicine focus (OR 2.6, CI 1.4-4.6); patients with an altered consciousness (OR 3.3, CI 1.6-6.6); treatment by physicians of the departments of surgery (OR 3.4, CI 2.2-5.2), internal medicine (OR 2.6, CI 1.9-3.7), or pulmonology (OR 2.2, CI 1.4-3.6); and urgency category of ≥ U1. Awareness of factors associated with prolonged LOS of older patients presenting at the ED is essential. Physicians should recognize and take these factors into account, in order to improve clinical outcomes of the (strongly increasing) population of older patients at the ED.

Crowding in the emergency department in the absence of boarding - a transition regression model to predict departures and waiting time

Background

Crowding in the emergency department (ED) is associated with increased mortality, increased treatment cost, and reduced quality of care. Crowding arises when demand exceed resources in the ED and a first sign may be increasing waiting time. We aimed to quantify predictors for departure from the ED, and relate this to waiting time in the ED before departure.

Methods

We utilised administrative data from the ED and calculated number of arrivals, departures, and the resulting queue in 30 min time steps for all of 2013 (N = 17,520). We build a transition model for each time step using the number of past departures and pre-specified risk factors (arrivals, weekday/weekend and shift) to predict the expected number of departures and from this the expected waiting time in the ED. The model was validated with data from the same ED collected March through August 2014.

Results

We found that the number of arrivals had the greatest independent impact on departures with an odds ratio of 0.942 (95%CI: 0.937;0.948) corresponding to additional 7 min waiting time per new arrival in a 30 min time interval with an a priori time spend in the ED of two hours. The serial correlation of departures was present up to one and a half hour previous but had very little effect on the estimates of the risk factors. Boarding played a negligible role in the studied ED.

Conclusions

We present a transition regression model with high predictive power to predict departures from the ED utilising only system level data. We use this to present estimates of expected waiting time and ultimately crowding in the ED. The model shows good internal validity though further studies are needed to determine generalisability to the performance in other settings.

Electronic supplementary material

The online version of this article (10.1186/s12874-019-0710-3) contains supplementary material, which is available to authorized users.

Evaluating the impact of emergency department crowding on disposition patterns and outcomes of discharged patients

BACKGROUND

Crowding is a major challenge faced by EDs and is associated with poor outcomes.

OBJECTIVES

Determine the effect of high ED occupancy on disposition decisions, return ED visits, and hospitalizations.

METHODS

We conducted a retrospective analysis of electronic health records of patients evaluated at an adult, urban, and academic ED over 20 months between the years 2012 and 2014. Using a logistic regression model predicting admission, we obtained estimates of the effect of high occupancy on admission disposition, adjusted for key covariates. We then stratified the analysis based on the presence or absence of high boarder patient counts.

RESULTS

Disposition decisions during a high occupancy hour decreased the odds of admission (OR = 0.93, 95% CI: [0.89, 0.98]). Among those who were not admitted, high occupancy was not associated with increased odds of return in the combined (OR = 0.94, 95% CI: [0.87, 1.02]), with-boarders (OR = 0.96, 95% CI: [0.86, 1.09]), and no-boarders samples (OR = 0.93, 95% CI: [0.83, 1.04]). Among those who were not admitted and who did return within 14 days, disposition during a high occupancy hour on the initial ED visit was not associated with a significant increased odds of hospitalization in the combined (OR = 1.04, 95% CI: [0.87, 1.24]), the with-boarders (OR = 1.12, 95% CI: [0.87, 1.44]), and the no-boarders samples (OR = 0.98, 95% CI: [0.77, 1.24]).

CONCLUSION

ED crowding was associated with reduced likelihood of hospitalization without increased likelihood of 2-week return ED visit or hospitalization. Furthermore, high occupancy disposition hours with high boarder patient counts were associated with decreased likelihood of hospitalization.

Characteristics of ED crowding in the Lazio Region (Italy) and short-term health outcomes

The effect of emergency department (ED) crowding on patient care has been studied for several years in the scientific literature. We evaluate the association between ED crowding and short-term mortality and hospitalization in the Lazio region (Italy) using two different measures. A cohort of visits in the Lazio region ED during 2012-2014 was enrolled. Only discharged patients were selected. ED crowding was estimated using two measures, length of stay (LOS), and Emergency Department volume (EDV). LOS was defined as the interval of time from entrance to discharge; EDV was defined at the time of each new entrance in ED. The outcomes under study were mortality and hospitalization within 7 days from ED discharge. A multivariate logistic model was performed (Odds Ratios, ORs, 95% CI). The cohort includes 2,344,572 visits. ED crowding is associated with an increased risk of short-term hospitalization using both LOS and EDV as exposures (LOS 1-2 h: OR = 1.71, 95% CI 1.66-1.76, LOS 2-5 h: OR = 1.38, 95% CI 1.34-1.43, LOS > 5 h OR = 1.45 95% CI 1.40-1.50 compared to patients with 1 h of LOS; EDV 75°-95° percentile: OR = 1.02, 95% CI 0.99-1.05 and EDV > 95° percentile: OR = 1.06, 95% CI 1.01-1.11 compared to patients with a EDV < 75° percentile upon arrival). Increased risk of short-term mortality is found with increasing level of LOS. High levels of EDV at the time of patients' arrival and longer LOS in ED are associated with greater risks of hospitalization for patients discharged 7 days before. LOS in ED is also associated with an increased risk of mortality.

Emergency department length of stay for ethanol intoxication encounters

BACKGROUND

Emergency Department (ED) encounters for ethanol intoxication are becoming increasingly common. The purpose of this study was to explore factors associated with ED length of stay (LOS) for ethanol intoxication encounters.

METHODS

This was a multi-center, retrospective, observational study of patients presenting to the ED for ethanol intoxication. Data were abstracted from the electronic medical record. To explore factors associated with ED LOS, we created a mixed-effects generalized linear model.

RESULTS

We identified 18,664 eligible patients from 6 different EDs during the study period (2012-2016). The median age was 37years, 69% were male, and the median ethanol concentration was 213mg/dL. Median LOS was 348min (range 43-1658). Using a mixed-effects generalized linear model, independent variables associated with a significant increase in ED LOS included use of parenteral sedation (beta=0.30, increase in LOS=34%), laboratory testing (beta=0.21, increase in LOS=23%), as well as the hour of arrival to the ED, such that patients arriving to the ED during evening hours (between 18:00 and midnight) had up to an 86% increase in LOS. Variables not significantly associated with an increase in LOS included age, gender, ethanol concentration, psychiatric disposition, using the ED frequently for ethanol intoxication, CT use, and daily ED volume.

CONCLUSION

Variables such as diagnostic testing, treatments, and hour of arrival may influence ED LOS in patients with acute ethanol intoxication. Identification and further exploration of these factors may assist in developing hospital and community based improvements to modify LOS in this population.

Factors associated with failure of emergency wait-time targets for high acuity discharges and intensive care unit admissions

Objective

Ontario established emergency department length-of-stay (EDLOS) targets but has difficulty achieving them. We sought to determine predictors of target time failure for discharged high acuity patients and intensive care unit (ICU) admissions.

Methods

This was a retrospective, observational study of 2012 Sunnybrook Hospital emergency department data. The main outcome measure was failing to meet government EDLOS targets for high acuity discharges and ICU emergency admissions. The secondary outcome measures examined factors for low acuity discharges and all admissions, as well as a run chart for 2015 – 2016 ICU admissions. Multiple logistic regression models were created for admissions, ICU admissions, and low and high acuity discharges. Predictor variables were at the patient level from emergency department registries.

Results

For discharged high acuity patients, factors predicting EDLOS target failure were having physician initial assessment duration (PIAD)>2 hours (OR 5.63 [5.22-6.06]), consultation request (OR 10.23 [9.38-11.14]), magnetic resonance imaging (MRI) (OR 19.33 [12.94-28.87]), computed tomography (CT) (OR 4.24 [3.92-4.59]), and ultrasound (US) (OR 3.47 [3.13-3.83]). For ICU admissions, factors predicting EDLOS target failure were bed request duration (BRD)>6 hours (OR 364.27 [43.20-3071.30]) and access block (AB)>1 hour (OR 217.27 [30.62-1541.63]). For discharged low acuity patients, factors predicting failure for the 4-hour target were PIAD>2 hours (OR 15.80 [13.35-18.71]), consultation (OR 20.98 [14.10-31.22]), MRI (OR 31.68 [6.03-166.54]), CT (OR 16.48 [10.07-26.98]), and troponin I (OR 13.37 [6.30-28.37]).

Conclusion

Sunnybrook factors predicting failure of targets for high acuity discharges and ICU admissions were hospital-controlled. Hospitals should individualize their approach to shortening EDLOS by analysing its patient population and resource demands.

A 'busy day' effect on perinatal complications of delivery on weekends: a retrospective cohort study

Objective

To evaluate whether busy days on a labour and delivery unit are associated with maternal and neonatal complications of childbirth in California hospitals, accounting for weekday/weekend births.

Design

This is a population-based retrospective cohort study.

Setting

Linked vital statistics/patient discharge data for California births between 2009 and 2010 from the Office of Statewide Health Planning and Development.

Participants

All singleton, cephalic, non-anomalous California births between 2009 and 2010 (N=724 967).

Main outcomes

The key exposure was high daily obstetric volume, defined as giving birth on a day when the number of births exceeded the hospital-specific 75th percentile of daily delivery volume. Outcomes were a range of maternal and neonatal complications.

Results

Several maternal and neonatal complications were increased on high-volume days and weekends following adjustment for maternal demographics, annual hospital birth volume and teaching hospital status. For example, compared with low-volume weekdays, the odds of Apgar <7 on low-volume weekend days and high-volume weekend days were 11% (adjusted OR (aOR) 1.11, CI 1.03 to 1.21) and 29% higher (aOR 1.29, CI 1.10 to 1.52), respectively. High volume was associated with increased odds of neonatal seizures on weekdays (aOR 1.33, CI 1.01 to 1.71) and haemorrhage on weekends (aOR 1.11, CI 1.01 to 1.22). After accounting for between-hospital variation, weekend delivery remained significantly associated with increased odds of Apgar score <7, neonatal intensive care unit admission, prolonged maternal length of stay and the odds of neonatal seizures remained increased on high-volume weekdays.

Conclusions

Our findings suggest that weekend delivery is a consistent risk factor for a range of perinatal complications and there may be variability in how well hospitals handle surges in volume.

A generic method for evaluating crowding in the emergency department

Background

Crowding in the emergency department (ED) has been studied intensively using complicated non-generic methods that may prove difficult to implement in a clinical setting. This study sought to develop a generic method to describe and analyse crowding from measurements readily available in the ED and to test the developed method empirically in a clinical setting.

Methods

We conceptualised a model with ED patient flow divided into separate queues identified by timestamps for predetermined events. With temporal resolution of 30 min, queue lengths were computed as Q(t + 1) = Q(t) + A(t) – D(t), with A(t) = number of arrivals, D(t) = number of departures and t = time interval. Maximum queue lengths for each shift of each day were found and risks of crowding computed. All tests were performed using non-parametric methods. The method was applied in the ED of Aarhus University Hospital, Denmark utilising an open cohort design with prospectively collected data from a one-year observation period.

Results

By employing the timestamps already assigned to the patients while in the ED, a generic queuing model can be computed from which crowding can be described and analysed in detail. Depending on availability of data, the model can be extended to include several queues increasing the level of information. When applying the method empirically, 41,693 patients were included. The studied ED had a high risk of bed occupancy rising above 100 % during day and evening shift, especially on weekdays. Further, a ‘carry over’ effect was shown between shifts and days.

Conclusions

The presented method offers an easy and generic way to get detailed insight into the dynamics of crowding in an ED.

Improved quality and efficiency after the introduction of physician-led team triage in an emergency department

BACKGROUND

Overcrowding in the emergency department (ED) may negatively affect patient outcomes, so different triage models have been introduced to improve performance. Physician-led team triage obtains better results than other triage models. We compared efficiency and quality measures before and after reorganization of the triage model in the ED at our county hospital.

MATERIALS AND METHODS

We retrospectively compared two study periods with different triage models: nurse triage in 2008 (baseline) and physician-led team triage in 2012 (follow-up). Physician-led team triage was in use during day-time and early evenings on weekdays. Data were collected from electronic medical charts and the National Mortality Register.

RESULTS

We included 20,073 attendances in 2008 and 23,765 in 2012. The time from registration to physician presentation decreased from 80 to 33 min (P < 0.001), and the length of stay decreased from 219 to 185 min (P < 0.001) from 2008 to 2012, respectively. All of the quality variables differed significantly between the two periods, with better results in 2012. The odds ratio for patients who left before being seen or before treatment was completed was 0.62 (95% confidence interval 0.54-0.72). The corresponding result for unscheduled returns was 0.36 (0.32-0.40), and for the mortality rates within 7 and 30 days 0.72 (0.59-0.88) and 0.84 (0.73-0.97), respectively. The admission rate was 37% at baseline and 32% at follow-up (P < 0.001).

CONCLUSION

Physician-led team triage improved the efficiency and quality in EDs.

Emergency Department Crowding and Outcomes After Emergency Department Discharge

STUDY OBJECTIVE

We assess whether a panel of emergency department (ED) crowding measures, including 2 reported by the Centers for Medicare & Medicaid Services (CMS), is associated with inpatient admission and death within 7 days of ED discharge.

METHODS

We conducted a retrospective cohort study of ED discharges, using data from an integrated health system for 2008 to 2010. We assessed patient transit-level (n=3) and ED system-level (n=6) measures of crowding, using multivariable logistic regression models. The outcome measures were inpatient admission or death within 7 days of ED discharge. We defined a clinically important association by assessing the relative risk ratio and 95% confidence interval (CI) difference and also compared risks at the 99th percentile and median value of each measure.

RESULTS

The study cohort contained a total of 625,096 visits to 12 EDs. There were 16,957 (2.7%) admissions and 328 (0.05%) deaths within 7 days. Only 2 measures, both of which were patient transit measures, were associated with the outcome. Compared with a median evaluation time of 2.2 hours, the evaluation time of 10.8 hours (99th percentile) was associated with a relative risk of 3.9 (95% CI 3.7 to 4.1) of an admission. Compared with a median ED length of stay (a CMS measure) of 2.8 hours, the 99th percentile ED length of stay of 11.6 hours was associated with a relative risk of 3.5 (95% CI 3.3 to 3.7) of admission. No system measure of ED crowding was associated with outcomes.

CONCLUSION

Our findings suggest that ED length of stay is a proxy for unmeasured differences in case mix and challenge the validity of the CMS metric as a safety measure for discharged patients.

Hand Hygiene Compliance in an Emergency Department: The Effect of Crowding

OBJECTIVES

Emergency department (ED) crowding results from the need to see high volumes of patients of variable acuity within a limited physical space. ED crowding has been associated with poor patient outcomes and increased mortality. The authors evaluated whether ED crowding is also associated with reduced hand hygiene compliance among health care workers.

METHODS

A trained observer measured hand hygiene compliance using standardized definitions for 22 months in the 40-bed ED of a 475-bed academic hospital in Toronto, Ontario, Canada. ED crowding measures, including mean daily patient volumes, time to initial physician assessment, and daily nursing hours, were obtained from hospital administrative and human resource databases. Known predictors of hand hygiene compliance, including the indication for hand hygiene and the health care workers' professions, were also measured. Hand hygiene data, measured during 20-minute observation sessions, were linked to aggregate daily results for each crowding metric. Crowding metrics and known predictors of hand hygiene compliance were then included in a multivariate model if associated with hand hygiene compliance at a p-value of <0.20.

RESULTS

Hand hygiene compliance was 29% (325 of 1,116 opportunities). Alcohol-based hand rinse was used 66% of the time. Nurses accounted for 68% of hand hygiene opportunities and physicians for 18%, with the remaining 14% attributed to nonphysician, nonnurse health care workers. The most common indications for hand hygiene were hand hygiene prior to (35%) and hand hygiene following (52%) contact with the patient or his or her environment. In multivariate analysis, time to physician assessment > 1.5 hours was associated with lower compliance (odds ratio [OR] = 0.67, 95% confidence interval [CI] = 0.51 to 0.89). Additionally, compliance was lower for nonnurse, nonphysician health care workers (OR = 0.51, 95% CI = 0.33 to 0.79) and higher for hand hygiene performed after contact with the patients or his/her environment, compared to hand hygiene performed before contact with the patient or his/her environment (OR = 2.0, 95% CI = 1.5 to 2.7). Daily patient volumes and nursing hours were not associated with hand hygiene compliance.

CONCLUSIONS

ED hand hygiene compliance was low. Increased time to physician assessment was associated with reduced compliance, suggesting an association between crowding and compliance. Strategies that minimize ED crowding may improve ED hand hygiene compliance.

Organisational Factors Induce Prolonged Emergency Department Length of Stay in Elderly Patients--A Retrospective Cohort Study

Study objective

To assess the association of patient and organisational factors with emergency department length of stay (ED-LOS) in elderly ED patients (226565 years old) and in younger patients (<65 years old).

Methods

A retrospective cohort study of internal medicine patients visiting the emergency department between September 1^st 2010 and August 31^st 2011 was performed. All emergency department visits by internal medicine patients 226565 years old and a random sample of internal medicine patients <65 years old were included. Organisational factors were defined as non-medical factors. ED-LOS is defined as the time between ED arrival and ED discharge or admission. Prolonged ED-LOS is defined as ≥75^th percentile of ED-LOS in the study population, which was 208 minutes.

Results

Data on 1782 emergency department visits by elderly patients and 597 emergency department visits by younger patients were analysed. Prolonged ED-LOS in elderly patients was associated with three organisational factors: >1 consultation during the emergency department visit (odds ratio (OR) 3.2, 95% confidence interval (CI) 2.3–4.3), a higher number of diagnostic tests (OR 1.2, 95% CI 1.16–1.33) and evaluation by a medical student or non-trainee resident compared with a medical specialist (OR 4.2, 95% CI 2.0–8.8 and OR 2.3, 95% CI 1.4–3.9). In younger patients, prolonged ED-LOS was associated with >1 consultation (OR 2.6, 95% CI 1.4–4.6). Factors associated with shorter ED-LOS were arrival during nights or weekends as well as a high urgency level in elderly patients and self-referral in younger patients.

Conclusion

Organisational factors, such as a higher number of consultations and tests in the emergency department and a lower seniority of the physician, were the main aspects associated with prolonged ED-LOS in elderly patients. Optimisation of the organisation and coordination of emergency care is important to accommodate the needs of the continuously growing number of elderly patients in a better way.

Triage-based resource allocation and clinical treatment protocol on outcome and length of stay in the emergency department

OBJECTIVE

The present study aimed to determine the relationship between the triage-based resource allocation and clinical treatment (TRACT) protocol and mortality and length of stay (LOS) in ED.

METHODS

This before-and-after study was conducted in an adult, tertiary, teaching hospital ED from August 2008 to July 2012. Patients who were younger than 18 years of age, who were dead on arrival and whose triage information was not available were excluded. TRACT was implemented in August 2010, and the Emergency Severity Index (ESI) was used for triage. Primary and secondary outcomes were ED mortality and ED LOS. Multivariate logistic regression models for ED mortality and multivariable general linear models on the ED LOS were used to compare the before- and after-intervention periods.

RESULTS

For the 155 563 visits over study period, the ED mortality rate was 0.2%, and the ED LOS was 4.6 h (median). The adjusted odds ratios (95% confidence intervals [CIs]) of the TRACT protocol on ED mortality were 0.69 (0.54-0.88) for total patients, 0.42 (0.30-0.59) for ESI 1, 1.04 (0.66-1.65) for ESI 2 and 1.45 (0.76-2.75) for ESI 3 group. The adjusted coefficients (95% CIs) of the TRACT on the ED LOS were -88.1 (-96.9 ∼ -79.2) min for all patients, -44.9 (-72.0 ∼ -17.9) min for ESI level 2 and -104.3 (-114.7 ∼ -94.0) min for ESI level 3.

CONCLUSIONS

The TRACT protocol decreased the ED mortality in ESI 1 group and reduced the ED LOS in ESI levels 2 and 3 groups.

Association among Emergency Department Volume Changes, Length of Stay, and Leaving Before Treatment Complete

The authors examined the association between the size of an emergency department (ED), volume increases over time, length of stay (LOS), and left before treatment complete (LBTC). EDs participating in the Emergency Department Benchmarking Alliance providing at least two years of data from 2004 to 2011 were included in the analysis. The impact of volume on LOS and LBTC varied depending on annual ED volume. Based on this, EDs can anticipate better how changes in volume will impact patient throughput in the future.

Impact of a physician-in-triage process on resident education

INTRODUCTION

Emergency department (ED) crowding negatively impacts patient care quality and efficiency. To reduce crowding many EDs use a physician-in-triage (PIT) process. However, few studies have evaluated the effect of a PIT processes on resident education. Our objective was to determine the impact of a PIT process implementation on resident education within the ED of an academic medical center.

METHODS

We performed a prospective cross-sectional study for a 10-week period from March to June 2011, during operationally historic trended peak patient volume and arrival periods. Emergency medicine residents (three-year program) and faculty, blinded to the research objectives, were asked to evaluate the educational quality of each shift using a 5-point Likert scale. Residents and faculty also completed a questionnaire at the end of the study period assessing the perceived impact of the PIT process on resident education, patient care, satisfaction, and throughput. We compared resident and attending data using Mann-Whitney U tests.

RESULTS

During the study period, 54 residents and attendings worked clinically during the PIT process with 78% completing questionnaires related to the study. Attendings and residents indicated "no impact" of the PIT process on resident education [median Likert score of 3.0, inter-quartile range (IQR): 2-4]. There was no difference in attending and resident perceptions (p-value =0.18). Both groups perceived patient satisfaction to be "positively impacted" [4.0, IQR:2-4 for attendings vs 4.0, IQR:1-5 for residents, p-value =0.75]. Residents perceived more improvement in patient throughput to than attendings [3.5, IQR:3-4 for attendings vs 4.0, IQR:3-5 for residents, p-value =0.006]. Perceived impact on differential diagnosis generation was negative in both groups [2.0, IQR:1-3 vs 2.5, IQR:1-5, p-value = 0.42]. The impact of PIT on selection of diagnostic studies and medical decision making was negative for attendings and neutral for residents: [(2.0, IQR:1-3 vs 3.0, IQR:1-4, p-value =0.10) and (2.0, IQR:1-4 vs 3.0, IQR:1-5, p-value =0.14 respectively].

CONCLUSION

Implementation of a PIT process at an academic medical center was not associated with a negative (or positive) perceived impact on resident education. However, attendings and residents felt that differential diagnosis development was negatively impacted. Attendings also felt diagnostic test selection and medical decision-making learning were negatively impacted by the PIT process.

Emergency department crowding predicts admission length-of-stay but not mortality in a large health system

BACKGROUND

Emergency department (ED) crowding has been identified as a major threat to public health.

OBJECTIVES

We assessed patient transit times and ED system crowding measures based on their associations with outcomes.

RESEARCH DESIGN

Retrospective cohort study.

SUBJECTS

We accessed electronic health record data on 136,740 adults with a visit to any of 13 health system EDs from January 2008 to December 2010.

MEASURES

Patient transit times (waiting, evaluation and treatment, boarding) and ED system crowding [nonindex patient length-of-stay (LOS) and boarding, bed occupancy] were determined. Outcomes included individual inpatient mortality and admission LOS. Covariates included demographic characteristics, past comorbidities, severity of illness, arrival time, and admission diagnoses.

RESULTS

No patient transit time or ED system crowding measure predicted increased mortality after control for patient characteristics. Index patient boarding time and lower bed occupancy were associated with admission LOS (based on nonoverlapping 95% CI vs. the median value). As boarding time increased from none to 14 hours, admission LOS increased an additional 6 hours. As mean occupancy decreased below the median (80% occupancy), admission LOS decreased as much as 9 hours.

CONCLUSIONS

Measures indicating crowded ED conditions were not predictive of mortality after case-mix adjustment. The first half-day of boarding added to admission LOS rather than substituted for it. Our findings support the use of boarding time as a measure of ED crowding based on robust prediction of admission LOS. Interpretation of measures based on other patient ED transit times may be limited to the timeliness of care.

The effect of an ambulance diversion ban on emergency department length of stay and ambulance turnaround time

STUDY OBJECTIVE

Massachusetts became the first state in the nation to ban ambulance diversion in 2009. It was feared that the diversion ban would lead to increased emergency department (ED) crowding and ambulance turnaround time. We seek to characterize the effect of a statewide ambulance diversion ban on ED length of stay and ambulance turnaround time at Boston-area EDs.

METHODS

We conducted a retrospective, pre-post observational analysis of 9 Boston-area hospital EDs before and after the ban. We used ED length of stay as a proxy for ED crowding. We compared hospitals individually and in aggregate to determine any changes in ED length of stay for admitted and discharged patients, ED volume, and turnaround time.

RESULTS

No ED experienced an increase in ED length of stay for admitted or discharged patients or ambulance turnaround time despite an increase in volume for several EDs. There was an overall 3.6% increase in ED volume in our sample, a 10.4-minute decrease in length of stay for admitted patients, and a 2.2-minute decrease in turnaround time. When we compared high- and low-diverting EDs separately, neither saw an increase in length of stay, and both saw a decrease in turnaround time.

CONCLUSION

After the first statewide ambulance diversion ban, there was no increase in ED length of stay or ambulance turnaround time at 9 Boston-area EDs. Several hospitals actually experienced improvements in these outcome measures. Our results suggest that the ban did not worsen ED crowding or ambulance availability at Boston-area hospitals.

Effect of emergency department crowding on outcomes of admitted patients

STUDY OBJECTIVE

Emergency department (ED) crowding is a prevalent health delivery problem and may adversely affect the outcomes of patients requiring admission. We assess the association of ED crowding with subsequent outcomes in a general population of hospitalized patients.

METHODS

We performed a retrospective cohort analysis of patients admitted in 2007 through the EDs of nonfederal, acute care hospitals in California. The primary outcome was inpatient mortality. Secondary outcomes included hospital length of stay and costs. ED crowding was established by the proxy measure of ambulance diversion hours on the day of admission. To control for hospital-level confounders of ambulance diversion, we defined periods of high ED crowding as those days within the top quartile of diversion hours for a specific facility. Hierarchic regression models controlled for demographics, time variables, patient comorbidities, primary diagnosis, and hospital fixed effects. We used bootstrap sampling to estimate excess outcomes attributable to ED crowding.

RESULTS

We studied 995,379 ED visits resulting in admission to 187 hospitals. Patients who were admitted on days with high ED crowding experienced 5% greater odds of inpatient death (95% confidence interval [CI] 2% to 8%), 0.8% longer hospital length of stay (95% CI 0.5% to 1%), and 1% increased costs per admission (95% CI 0.7% to 2%). Excess outcomes attributable to periods of high ED crowding included 300 inpatient deaths (95% CI 200 to 500 inpatient deaths), 6,200 hospital days (95% CI 2,800 to 8,900 hospital days), and $17 million (95% CI $11 to $23 million) in costs.

CONCLUSION

Periods of high ED crowding were associated with increased inpatient mortality and modest increases in length of stay and costs for admitted patients.

Executive summary: interventions to improve quality in the crowded emergency department

Emergency department (ED) crowding is a major public health problem in the United States, with increasing numbers of ED visits, longer lengths of stay in the ED, and the common practice of ED boarding. In the next several years, several measures of ED crowding will be assessed and reported on government websites. In addition, with the implementation of the Affordable Care Act (ACA), millions more Americans will have health care insurance, many of whom will choose the ED for their care. In June 2011, a consensus conference was conducted in Boston, Massachusetts, by the journal Academic Emergency Medicine entitled "Interventions to Assure Quality in the Crowded Emergency Department." The overall goal of the conference was to develop a series of research agendas to identify promising interventions to safeguard the quality of emergency care during crowded periods and to reduce ED crowding altogether through systemwide solutions. This was achieved through three objectives: 1) a review of interventions that have been implemented to reduce crowding and summarize the evidence of their effectiveness on the delivery of emergency care; 2) to identify strategies within or outside of the health care setting (i.e., policy, engineering, operations management, system design) that may help reduce crowding or improve the quality of emergency care provided during episodes of ED crowding; and 3) to identify the most appropriate design and analytic techniques for rigorously evaluating ED interventions designed to reduce crowding or improve the quality of emergency care provided during episodes of ED crowding. This article describes the background and rationale for the conference and highlights some of the discussions that occurred on the day of the conference. A series of manuscripts on the details of the conference is presented in this issue of Academic Emergency Medicine.