Emergency Department Crowding and Outcomes After Emergency Department Discharge - 21/10/15
, Stephen F. Derose, MD, MSHS b, Vicki Y. Chiu, MS b, Sau C. Yiu, MS b, Catherine A. Sarkisian, MD, MSPH a, Jason P. Jones, PhD b, Benjamin C. Sun, MD, MPP cAbstract |
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.
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| Please see page 484 for the Editor’s Capsule Summary of this article. |
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| Supervising editor: Donald M. Yealy, MD |
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| Author contributions: GZG, SFD, and BCS conceived the study and designed the analysis. BCS obtained research funding. JPJ linked the data. VYC and SCY managed the data, conducted the analyses, and provided statistical advice. CAS aided in study design and oversight. GZG drafted the article, and all authors contributed substantially to its revision. BCS takes responsibility for the paper as a whole. |
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| Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/). The authors have stated that no such relationships exist and provided the following details: This research was supported by the Agency for Healthcare Research and Quality (AHRQ) (R03 HS18994 to Dr. Sun) and Kaiser Permanente of Southern California. Dr. Gabayan receives support from the National Institutes of Health (NIH)/National Center for Research Resources (NCRR)/National Center for Advancing Translational Sciences (NCATS) University of California, Los Angeles (UCLA) Clinical and Translational Science Institute (CTSI) (grant KL2TR000122). |
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| The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or AHRQ. The funding organizations did not have a role in the design and conduct of the study; management, analysis, and interpretation of the data; and preparation, review, or approval of the article. |
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Vol 66 - N° 5
P. 483 - novembre 2015 Retour au numéro
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