Association of emergency department crowding with inpatient outcomes

Hsuan, Charleen; Segel, Joel E.; Hsia, Renee Y.; Wang, Yinan; Rogowski, Jeannette

doi:10.1111/1475-6773.14076

Cited by 11 publications

(4 citation statements)

References 63 publications

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“…First, although not true for all public hospitals or conditions, 25 safety net hospitals26–29 and public hospitals 30 on average score worse on public reporting, readmissions, and quality improvement metrics than nonpublic hospitals. Second, safety net hospitals are often overcrowded, and ED overcrowding is associated with adverse outcomes including higher mortality, both for ED patients 31–34 and inpatients in those hospitals 35,36 . Thus transfers to already‐overburdened safety net hospitals might worsen patient outcomes, both for the transferred patient and for patients already at those safety net hospitals.…”

Section: Introductionmentioning

confidence: 99%

“…Second, safety net hospitals are often overcrowded, and ED overcrowding is associated with adverse outcomes including higher mortality, both for ED patients 31 , 32 , 33 , 34 and inpatients in those hospitals. 35 , 36 Thus transfers to already‐overburdened safety net hospitals might worsen patient outcomes, both for the transferred patient and for patients already at those safety net hospitals. Third, racial and ethnic differences in where patients are transferred—if not explained by geography, insurance, or condition—may suggest a dual standard of treatment, particularly given the historical context of EMTALA and patient dumping.…”

Section: Introductionmentioning

confidence: 99%

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Racial and ethnic disparities in emergency department transfers to public hospitals

Hsuan,

Vanness,

Zebrowski

et al. 2024

Health Services Research

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ObjectiveTo examine racial/ethnic differences in emergency department (ED) transfers to public hospitals and factors explaining these differences.Data Sources and Study SettingED and inpatient data from the Healthcare Cost and Utilization Project for Florida (2010–2019); American Hospital Association Annual Survey (2009–2018).Study DesignLogistic regression examined race/ethnicity and payer on the likelihood of transfer to a public hospital among transferred ED patients. The base model was controlled for patient and hospital characteristics and year fixed effects. Models II and III added urbanicity and hospital referral region (HRR), respectively. Model IV used hospital fixed effects, which compares patients within the same hospital. Models V and VI stratified Model IV by payer and condition, respectively. Conditions were classified as emergency care sensitive conditions (ECSCs), where transfer is protocolized, and non‐ECSCs. We reported marginal effects at the means.Data Collection/Extraction MethodsWe examined 1,265,588 adult ED patients transferred from 187 hospitals.Principal FindingsBlack patients were more likely to be transferred to public hospitals compared with White patients in all models except ECSC patients within the same initial hospital (except trauma). Black patients were 0.5–1.3 percentage points (pp) more likely to be transferred to public hospitals than White patients in the same hospital with the same payer. In the base model, Hispanic patients were more likely to be transferred to public hospitals compared with White patients, but this difference reversed after controlling for HRR. Hispanic patients were − 0.6 pp to −1.2 pp less likely to be transferred to public hospitals than White patients in the same hospital with the same payer.ConclusionsLarge population‐level differences in whether ED patients of different races/ethnicities were transferred to public hospitals were largely explained by hospital market and the initial hospital, suggesting that they may play a larger role in explaining differences in transfer to public hospitals, compared with other external factors.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Racial and ethnic disparities in emergency department transfers to public hospitals

Hsuan,

Vanness,

Zebrowski

et al. 2024

Health Services Research

Self Cite

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“…This adds time to ED patient disposition and costs to the healthcare system [ 7 , 8 ]. Given the negative association between ED crowding and adverse clinical outcomes, we must evaluate ways to reduce excess testing and decrease disposition time [ 9 , 10 ]. Furthermore, ED length of stay is inversely associated with patient satisfaction [ 11 ].…”

Section: Introductionmentioning

confidence: 99%

History, ECG, Risk Factors (HER) Scoring for Cardiac Risk Stratification in Patients <45 Years of Age Presenting With Chest Pain

Legare¹,

Dunn²,

Arner³

et al. 2023

Cureus

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Background Chest pain is a common chief complaint of patients presenting to the emergency department. Acute coronary syndrome (ACS) is found to be the etiology of this symptom in a minority of these patient encounters. This study aimed to determine the utility of using the History, ECG, Risk Factors (HER) components of the History, ECG, Age, Risk Factors, Troponin (HEART) score in ruling out 30-day Major Adverse Cardiac Event (MACE), ACS, ventricular tachycardia, and ventricular fibrillation in patients aged less than 45. Additionally, the utility of this score in ruling out a positive troponin was investigated as well. Methodology This is a retrospective chart review study that examined a consecutive cohort of 7,724 patients presenting with chest pain to the 11 emergency departments of a single healthcare system over a two-year period (January 2019 to December 2020). HER scores of 0 to 1 were categorized as negative (-) and scores of two or greater were categorized as positive (+). Sensitivity, specificity, and predictive values were calculated for the relationship between HER score positivity and primary cardiac disease and troponin results. Results Test characteristics of HER scoring for significant primary cardiac disease in patients between 18 and 45 years of age presenting with undifferentiated chest pain were sensitivity of 88.0 (CI = 80.0-94.0), specificity of 72.6 (CI = 71.8-73.8), positive predictive value of 3.1 (CI = 2.4-3.9), and negative predictive value of 99.8 (CI = 99.7-99.9). Furthermore, an HER score >1 was neither sensitive nor specific in predicting a positive troponin (sensitivity = 80, CI = 71.9-86; specificity = 71.3, CI = 70.3-72.3). However, the negative predictive value of an HER score of 0-1 was 99.5 (CI = 99.3-99.7) and the positive predictive value was 4.7 (CI = 3.9-5.7). Conclusions According to this study, when evaluating young patients who are deemed to have a subjectively non-highly suspicious history, who have minimal risk factors, and who have an ECG without significant ST deviation, troponin testing is low yield in the risk stratification of patients under the age of 45 for serious primary cardiac disease.

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“…Increased length of stay (LOS) in the ED is associated with increased mortality, medical errors, delays in care, and decreased quality of care. 1 , 2 One factor in longer ED LOS is inefficient subspecialty consultation—awaiting consultation is associated with a prolonged inpatient stay, and conversely increasing consultant staffing may reduce LOS. 3 An essential part of the consultation is 2‐way communication.…”

Section: Introductionmentioning

confidence: 99%

Improvements to emergency department length of stay and user satisfaction after implementation of an integrated consult order

et al. 2023

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Objective Subspecialty consultation in the emergency department (ED) is a vital, albeit time consuming, part of modern medicine. Traditional consultation requires manual paging to initiate communication. Although consult orders through the electronic health record (EHR) may help, they do not facilitate 2‐way communication. However, the impact of combining these systems within the EHR is unknown. We estimated the effect of implementing an integrated paging system on ED workflow efficiency and user attitudes. Methods We integrated a messaging system into order entry at our tertiary care academic ED, such that placing a consult order simultaneously paged the consultant. We measured ED workflow efficiency metrics (length of stay [LOS], consult initiation time) and MD/nurse practitioner (NP)/physician assistant (PA) attitudes (perceived mis‐pages, efficiency, and workflow preference) 3 months before and 6 months after the implementation. Results Six months after implementation, there was 25% use of the new workflow. During the pre‐implementation phase, the median time to consult initiation and ED LOS were 150 and 621 minutes, respectively. Implementation of the order was associated with a 15‐minute reduction in median time to consult initiation ( P < 0.001), and a 52‐minute reduction in median ED LOS ( P < 0.001). ED MDs/NPs/PAs perceived a reduction in the rate of mis‐pages, improved efficiency, and overall preferred the new workflow. Conclusions We consolidated steps in the ED consult workflow using an integrated consult order, which improved user satisfaction, and reduced consult initiation time and ED LOS for patients requiring a consult at an urban tertiary care ED.

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Association of emergency department crowding with inpatient outcomes

Abstract: Objective: To examine the association of higher emergency department (ED) census with inpatient outcomes on the day of discharge (inpatient length of stay, in-hospital mortality, ED revisits, and readmissions).

Cited by 11 publications

References 63 publications

Racial and ethnic disparities in emergency department transfers to public hospitals

Racial and ethnic disparities in emergency department transfers to public hospitals

History, ECG, Risk Factors (HER) Scoring for Cardiac Risk Stratification in Patients <45 Years of Age Presenting With Chest Pain

Improvements to emergency department length of stay and user satisfaction after implementation of an integrated consult order

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