Better performance on length-of-stay benchmarks associated with reduced risk following emergency department discharge: an observational cohort study

Introduction

Emergency department (ED) crowding is associated with adverse outcomes. Several jurisdictions have established benchmarks and targets for length-of-stay (LOS) to reduce crowding. An evaluation has been conducted on whether performance on Ontario’s ED LOS benchmarks is associated with reduced risk of death or hospitalization.

Methods

A retrospective cohort study of discharged ED patients was conducted using population-based administrative data from Ontario (April 2008 to February 2012). For each ED visit, the proportion of patients seen during the same shift that met ED LOS benchmarks was determined. Performance was categorized as <80%, 80% to <90%, 90% to <95%, and 95%–100% of same-shift ED patients meeting the benchmark. Logistic regression models analysed the association between performance on ED LOS benchmarks and 7-day death or hospitalization, controlled for patient and ED characteristics and stratified by patient acuity.

Results

From 122 EDs, 2,295,256 high-acuity and 1,626,629 low-acuity visits resulting in discharge were included. Deaths and hospitalizations within 7 days totalled 1,429 (0.062%) and 49,771 (2.2%) among high-acuity, and 220 (0.014%) and 9,005 (0.55%) among low-acuity patients, respectively. Adverse outcomes generally increased among patients seen during shifts when a lower proportion of ED patients met ED LOS benchmarks. The adjusted odds ratios (and 95% confidence intervals) among high- and low-acuity patients seen on shifts when <80% met ED benchmarks (compared with ≥95%) were, respectively, 1.32 (1.05–1.67) and 1.84 (1.21–2.81) for death, and 1.13 (1.08–1.17) and 1.40 (1.31–1.49) for hospitalization.

Conclusions

Better performance on Ontario’s ED LOS benchmarks for each shift is associated with a 10%–45% relative reduction in the odds of death or admission 7 days after ED discharge.

Evaluating the effect of clinical decision units on patient flow in seven Canadian emergency departments

OBJECTIVES

To evaluate the effect of emergency department (ED) clinical decision units (CDUs) on overall ED patient flow in a pilot project funded in 2008 by the Ontario Ministry of Health and Long-Term Care (MOHLTC).

METHODS

A retrospective analysis of unscheduled ED visits at seven CDU pilot and nine control sites was conducted using administrative data. The authors examined trends in CDU utilization and compared outcomes between pilot-CDU and control sites 1 year prior to implementation, with the first 18 months of CDU operation. Sites that were unsuccessful in their applications for CDU program funding served as controls. Outcomes included ED length of stay (LOS), admission rates, and ED revisit rates.

RESULTS

At CDU sites, roughly 4% of ED patients were admitted to CDUs. The presence of a pilot-CDU was independently associated with a small reduction in ED LOS for all low-acuity patients (-0.14 hour, 95% confidence interval [CI]=-0.22 to -0.07) and nonadmitted patients (-0.11 hour, 95% CI=-0.16 to -0.07). A small independent effect on absolute hospital admission rate for all high-acuity patients (-0.8%, 95% CI=-1.5% to -0.03%) and moderate-acuity patients (-0.6%, 95% CI=-1.1% to -0.2%) was also observed. Pilot-CDUs were not associated with changes in ED revisit rates.

CONCLUSIONS

With only 4% of ED patients admitted to CDUs, the potential for efficiency gains in these EDs was limited. Nonetheless, these findings suggest small improvements in the operation of the ED through CDU implementation. Although marginal, the observed effects of CDU operation were in the desired direction of reduced ED LOS, reduced admission rate, and no increase in ED revisit rate.