A Research Agenda to Assure Equity During Periods of Emergency Department Crowding

Hwang, Ula; Weber, Ellen J; Richardson, Lynne D.; Sweet, Vicki; Todd, Knox H.; Abraham, Gallane; Ankel, Felix

doi:10.1111/j.1553-2712.2011.01233.x

Cited by 20 publications

(20 citation statements)

References 48 publications

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“…Overcrowding could affect treatment received and may increase differential treatment by reducing empathy toward disadvantaged groups. [11] Implicit bias has also been shown to be present within the ED setting for AI children and may lead to differential care, especially in the face of a busy ED. [12]…”

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confidence: 99%

Community Perspectives on Emergency Department Use and Care for American Indian Children

Pickner

Ziegler

Hanson

et al. 2017

J. Racial and Ethnic Health Disparities

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Emergency department (ED) utilization by American Indian (AI) children is among the highest in the nation. Numerous health disparities have been well documented in AI children, but limited information is available on parental experiences of care for AI children in the ED. Our objective was to understand parental attitudes towards ED care for AI children. Focus groups were held with AI parents/caregivers at five sites in the Upper Midwest. Traditional content analysis was used to identify themes. A total of 70 parents participated in ten focus groups. Three main themes were identified: healthcare environment, access to care, and interaction with providers. Healthcare environment issues included availability of specialists, wait times, and child-friendly areas. Transportation and financial considerations were major topics in access to care. Issues in interaction with providers included discrimination, stereotyping, and trust. This is one of the first studies to assess parent perspectives on ED use for AI children. Obtaining parental perspectives on ED experiences is critical to improve patient care and provide important information for ED providers.

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confidence: 99%

Community Perspectives on Emergency Department Use and Care for American Indian Children

Pickner

Ziegler

Hanson

et al. 2017

J. Racial and Ethnic Health Disparities

View full text Add to dashboard Cite

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“…Crowding may place physicians under information overload, 25 a state in which they are more likely to both commit errors and attempt escape from difficult tasks, 26 suggesting the potential for an increase in potentially avoidable admissions as ED physicians choose admission as a safe alternative for these gray area patients. One previous study has examined this association and found an association between crowding and increased likelihood of admission for transient ischemic attack patients in Canada; 27 to our knowledge this association has not been in investigated among all patients or in the United States.…”

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confidence: 99%

The Impact of Emergency Department Census on the Decision to Admit

Gorski

Batt

Ötleş

et al. 2017

Academic Emergency Medicine

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Objective: We evaluated the effect of emergency department (ED) census on disposition decisions made by ED physicians.Methods: We performed a retrospective analysis using 18 months of all adult patient encounters seen in the main ED at an academic tertiary care center. Patient census information was calculated at the time of physician assignment for each individual patient and included the number of patients in the waiting room (waiting room census) and number of patients being managed by the patient's attending (physician load census). A multiple logistic regression model was created to assess the association between these census variables and the disposition decision, controlling for potential confounders including Emergency Severity Index acuity, patient demographics, arrival hour, arrival mode, and chief complaint.Results: A total of 49,487 patient visits were included in this analysis, of whom 37% were admitted to the hospital. Both census measures were significantly associated with increased chance of admission; the odds ratio (OR) per patient increase for waiting room census was 1.011 (95% confidence interval [CI] = 1.001 to 1.020), and the OR for physician load census was 1.010 (95% CI = 1.002 to 1.019). To put this in practical terms, this translated to a modeled rise from 35.3% to 40.1% when shifting from an empty waiting room and zero patient load to a 12-patient wait and 16-patient load for a given physician. Conclusion:Waiting room census and physician load census at time of physician assignment were positively associated with the likelihood that a patient would be admitted, controlling for potential confounders. Our data suggest that disposition decisions in the ED are influenced not only by objective measures of a patient's disease state, but also by workflow-related concerns. E mergency care is receiving increasing scrutiny as a potential area for cost reductions.1-3 Management of emergency department (ED) costs begins with examining how ED operational characteristics contribute to both patient-level and system-level outcomes. One such characteristic under scrutiny is ED crowding, a phenomenon that can be partially attributed to rising practice intensity 4,5 and inpatient boarding. 6-8 As ED utilization rises, research on the effects of crowding has primarily focused on its influence on patient outcomes, including treatment delays 9-11 and patient mortality.12-15 Less well characterized are organizational responses to increasing operational pressure, such as changes to rates of admission.Highly relevant to the discussion of the cost of emergency care is the growing role of the ED as a "gatekeeper" for inpatient services. 1,16,17 In a 2013 RAND report, hospital admissions rose 4% from 34.7 The authors have no relevant financial information or potential conflicts to disclose. Author contributions: JKG, RJB, and BWP conceived the study; JKG conducted the primary data analysis, with advice and input from RJB and BWP; EO helped with data analysis and offered further methodologic input; JKG pri...

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“…For example, some evidence suggests that injury severity varies by race, thus warranting differential use of ADI [35, 37]. In addition, the extent of overcrowding in an ED has been shown to affect the thoroughness of patients’ evaluation, which disproportionately affects hospitals that serve higher number of African Americans [37, 38]. Other potential explanations for racial differences in ADI use include provider implicit bias [35], and/or potential overuse of ADI in white patients rather than underuse by African American patients [39].…”

Section: Discussionmentioning

confidence: 99%

Advanced diagnostic imaging utilization during emergency department visits in the United States: A predictive modeling study for emergency department triage

et al. 2019

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Background Emergency department (ED) crowding is associated with negative health outcomes, patient dissatisfaction, and longer length of stay (LOS). The addition of advanced diagnostic imaging (ADI), namely CT, ultrasound (U/S), and MRI to ED encounter work up is a predictor of longer length of stay. Earlier and improved prediction of patients’ need for advanced imaging may improve overall ED efficiency. The aim of the study was to detect the association between ADI utilization and the structured and unstructured information immediately available during ED triage, and to develop and validate models to predict utilization of ADI during an ED encounter. Methods We used the United States National Hospital Ambulatory Medical Care Survey data from 2009 to 2014 to examine which sociodemographic and clinical factors immediately available at ED triage were associated with the utilization of CT, U/S, MRI, and multiple ADI during a patient’s ED stay. We used natural language processing (NLP) topic modeling to incorporate free-text reason for visit data available at time of ED triage in addition to other structured patient data to predict the use of ADI using multivariable logistic regression models. Results Among the 139,150 adult ED visits from a national probability sample of hospitals across the U.S, 21.9% resulted in ADI use, including 16.8% who had a CT, 3.6% who had an ultrasound, 0.4% who had an MRI, and 1.2% of the population who had multiple types of ADI. The c-statistic of the predictive models was greater than or equal to 0.78 for all imaging outcomes, and the addition of text-based reason for visit information improved the accuracy of all predictive models. Conclusions Patient information immediately available during ED triage can accurately predict the eventual use of advanced diagnostic imaging during an ED visit. Such models have the potential to be incorporated into the ED triage workflow in order to more rapidly identify patients who may require advanced imaging during their ED stay and assist with medical decision-making.

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A Research Agenda to Assure Equity During Periods of Emergency Department Crowding

Cited by 20 publications

References 48 publications

Community Perspectives on Emergency Department Use and Care for American Indian Children

Community Perspectives on Emergency Department Use and Care for American Indian Children

The Impact of Emergency Department Census on the Decision to Admit

Advanced diagnostic imaging utilization during emergency department visits in the United States: A predictive modeling study for emergency department triage

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