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

ABSTRACT: Emergency department (ED) crowding has been identified as a major threat to public health.We assessed patient transit times and ED system crowding measures based on their associations with outcomes.Retrospective cohort study.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.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.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.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.

SUBMITTER: Derose SF

PROVIDER: S-EPMC5322760 | biostudies-literature | 2014 Jul

REPOSITORIES: biostudies-literature

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

Derose Stephen F SF Gabayan Gelareh Z GZ Chiu Vicki Y VY Yiu Sau C SC Sun Benjamin C BC

Medical care 20140701 7

<h4>Background</h4>Emergency department (ED) crowding has been identified as a major threat to public health.<h4>Objectives</h4>We assessed patient transit times and ED system crowding measures based on their associations with outcomes.<h4>Research design</h4>Retrospective cohort study.<h4>Subjects</h4>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.<h4>Measures</h4>Patient transit times (waiting, evaluati ...[more]

PMID: 24926707

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Project description:Performance measures, particularly pay for performance, may have unintended consequences for safety-net institutions caring for disproportionate shares of Medicaid or uninsured patients.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.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.Emergency Department length-of-stay measure compliance by disposition and safety-net status.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]).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.

Dataset Information

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

Publications

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

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