Associations between in-hospital bed occupancy and unplanned 72-h revisits to the emergency department: a register study

Abstract

BackgroundA possible downstream effect of high in-hospital bed occupancy is that patients in the emergency department (ED) who would benefit from in-hospital care are denied admission. The present study aimed at evaluating this hypothesis through investigating associations between in-hospital bed occupancy at the time of presentation in the ED and the probability for unplanned 72-hour (72-h) revisits to the ED among patients discharged at index. A second outcome was unplanned 72-h revisits resulting in admission.MethodsAll visits to the ED of a 420-bed emergency hospital in southern Sweden between 1 January 2011 and 31 December 2012, which did not result in admission, death, or transfer to another hospital were included. Revisiting fractions were computed for in-hospital occupancy intervals <85%, 85% to 90%, 90% to 95%, 95% to 100%, 100% to 105%, and ≥105%. Multivariate models were constructed in an attempt to take confounding factors from, e.g., presenting complaints, age, referral status, and triage priority into account.ResultsIncluded in the study are 81,878 visits. The fraction of unplanned 72-h revisits/unplanned 72-h revisits resulting in admission was 5.8%/1.4% overall, 6.2%/1.4% for occupancy <85%, 6.4%/1.5% for occupancy 85% to 90%, 5.8%/1.4% for occupancy 90% to 95%, 6.0%/1.6% for occupancy 95% to 100%, 5.4%/1.6% for occupancy 100% to 105%, and 4.9%/1.4% for occupancy ≥105%.In the multivariate models, a trend to lower probability of unplanned 72-h revisits was observed at occupancy ≥105% compared to occupancy <95% (OR 0.88, CI 0.76 to 1.01). No significant associations between in-hospital occupancy at index and the probability of making unplanned 72-h revisits resulting in admission were observed.ConclusionsThe lack of associations between in-hospital occupancy and unplanned 72-h revisits does not support the hypothesis that ED patients are inappropriately discharged when in-hospital beds are scarce. The results are reassuring as they indicate that physicians are able to make good decisions, also while resources are constrained.

Influence of Overcrowding in the Emergency Department on Return Visit within 72 Hours

“…The entire 72-hour RV rate has been most commonly used for monitoring ED performance [4,5,23,44], but many of the RVs are caused by patient's factors such as worry about health or illness's factors such as disease progression rather than medical error [1,9,20,23], and several researchers suggested that the rate of RVA may be a better indicator for reflecting the quality of healthcare [3,45]. In this study, the 72-hour RVA rate was 0.9% of total ED visits, similar to the 0.5-1.5% reported in previous studies [1,11,20]. The proportion of RVA in total RV was 29.7%, which was higher than the admission rate of 24.0% in all ED patients.…”

“…The number of boarding patients gradually increases from Monday to Friday, and then decreases on Friday afternoon. The median (IQR) value was 56 (44-68) for the total number of patients, 35 (26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44) for the number of evaluating patients, and 14 (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26) for the number of boarding patients. Therefore, the third quartile, the critical point of overcrowding was 68, 44, and 26, for total, evaluating, and boarding indicators, respectively.…”

“…However, one study that investigated whether inpatient occupancy affected the 72-hour RV rate of ED reported results that were not significant [11]. The hospital of Sweden where the abovementioned study was conducted has a strategy to facilitate the output of the ED; the Swedish government restricts the time spent in the emergency room to 4 hours, and the hospital operates a full-capacity protocol when the inpatient bed-occupancy rate reaches 100% [11]. The government's policy to limit the ED LOS brings about changes in the hospital system that facilitates patient flow [32], and the full-capacity protocol that hospitalizes boarding patients of the ED into the corridor of hospital wards in overcrowded situation is effective in resolving ED overcrowding [33,34].…”

“…Therefore, this reduced scope of admission would probably increase the possibility of RV by increasing the risk of inadequate or premature discharge. However, one study that investigated whether inpatient occupancy affected the 72-hour RV rate of ED reported results that were not significant [11]. The hospital of Sweden where the abovementioned study was conducted has a strategy to facilitate the output of the ED; the Swedish government restricts the time spent in the emergency room to 4 hours, and the hospital operates a full-capacity protocol when the inpatient bed-occupancy rate reaches 100% [11].…”

Patients presenting at the emergency department with acute abdominal pain are less likely to be admitted to inpatient wards at times of access block: a registry study

“…Recent studies have suggested that hospital crowding not only causes boarding in the ED, but also that ED patients are less likely to be admitted to the hospital at times of access block and instead are discharged home [ 16 ]. Such admission-bias may reflect a strategy by which ED staff averts inpatient admission in all but the sickest patients [ 16 , 17 ]. Patients with acute abdominal pain frequently seek care in the ED and different management strategies have emerged for those lacking immediate indications for surgical treatment [ 18 ].…”