Swamped and underfunded, emergency departments (EDs) provide less desirable care at higher cost; however, they offer what no other healthcare service does: reliable accessibility. Many visitors to EDs become annoyed because they endure long waits before receiving treatment. However, a new study has reported that, beyond annoyance, visitors to a crowded ED are at increased risk of death compared to those who present during slow periods. Researchers affiliated with Oregon Health & Science University, Portland published their findings online on December 10 in the Annals of Emergency Medicine.
The researchers noted that ED crowding is a significant health delivery problem and may adversely affect the outcomes of patients requiring admission. Therefore, they designed a study to assess the association of ED crowding with subsequent outcomes in a general population of hospitalized patients. The investigators conducted a retrospective analysis of patients admitted in 2007 through the EDs of nonfederal, acute care hospitals in California. They reviewed 995,379 ED visits resulting in admission to 187 hospitals. The primary outcome measure was inpatient mortality. Secondary outcome measures included hospital length of stay and costs. ED crowding was established by the measurement of ambulance diversion hours on the day of admission. Hospitals prohibited from diverting ambulances were excluded from the study, as were children's hospitals. Also included from the analysis were diversions for reasons other than ED saturation, such as the temporary lack of a subspecialty, were excluded from the analysis. In this study, crowding was defined as days within the top quartile of daily ambulance diversion for a specific facility.
To control for hospital-level confounders of ambulance diversion, they defined periods of high ED crowding as those days within the top quartile (25%) of diversion hours for a specific facility. The analysis was controlled for demographics, time variables, patient comorbidities (other health problems), primary diagnosis, and hospital fixed effects. They employed a method known as bootstrap sampling to estimate excess outcomes attributable to ED crowding.
The investigators found that patients who were admitted on days with high ED crowding experienced 5% greater odds of inpatient death, 0.8% longer hospital length of stay, and 1% increased costs per admission. They also found that patients admitted via a crowded ED had a 9% greater risk of dying within 3 days of admission. Excess bad outcomes attributable to periods of high ED crowding included 300 inpatient deaths, 6,200 hospital days, and $17 million in costs.
The authors concluded that periods of high ED crowding were associated with increased inpatient mortality and modest increases in length of stay, and costs for admitted patients.
Take home message:
This study notes an increased risk of death as well as increased healthcare costs associated with an ED visit. A significant factor in ED crowding is patients who use the facility as a substitute for traditional care with a physician. Some visit the ED because they cannot get an appointment in a timely manner with a physician. The Affordable Care Act, increasing doctor shortage, and population growth are likely to exacerbate ED crowding in the near future. If you take an ill friend or relative to the ED and suspect a serious health problem, act as the patient’s advocate and be assertive with ED personnel.
Reference: Annals of Emergency Medicine
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