Demand, overcrowding and the pediatric emergency department

Abstract

CMAJ | JUNE 10, 2019 | VOLUME 191 | ISSUE 23 E625 D emand on pediatric emergency departments is increasing. A linked study provides evidence that overcrowding in Canadian pediatric emergency departments negatively affects the care of both those triaged as requiring urgent care and those requiring less urgent care, by an increased rate of hospital admission and an increased rate of reattendance after discharge, respectively. 1 Doan and colleagues conducted a retrospective cohort study looking at more than 1.9 million attendances to 8 Canadian pediatric emergency departments over 5 years to determine whether overcrowding in the emergency department is associated with adverse outcomes -defined as hospital admission at the index visit, return to the department or hospital admission within 7 days of discharge from the emergency department, and mortality within 14 days.For policy-makers in the United Kingdom, this question has already been answered. The first evidence-based principle of the Keogh review of urgent and emergency care services -that "preventing crowding in emergency departments improves patient outcomes" 2 -drove a national effort to reduce emergency department attendances through the reconfiguration and promotion of community services. Although the authors of the linked research found no significant association between emergency department crowding and either hospital admission or mortality after discharge, they did not consider the full range of outcomes examined in other studies, which indicate that quality of treatment, provision of analgesia and patient experience are all negatively affected by overcrowding in the pediatric emergency department. 3,4 The lack of an increase in hospital admission within 7 days or mortality within 14 days shows an element of resilience among Canadian clinicians and emergency departments. However, Doan and colleagues did observe "an increase in the odds of hospital admission at the index visit with increasing departmental length of stay among the sickest children (Canadian Triage and Acuity Scale [CTAS]) 1-3)." This lowering of the threshold of admission may imply that decision-making became more risk averse during busy periods.Doan and colleagues' finding that the number of emergency department attendances increased by 27% over the 5-year study period is similar to the experience in England, where attendances by those younger than 15 years to emergency departments has increased by 60% over the past 10 years. 5 Increasing attendances at pediatric emergency departments pose a challenge to clinicians, emergency departments and health systems. Adjusting to overcrowding by lowering the threshold of admission is not a sustainable response. This need is well recognized by pediatric emergency medicine physicians; a recent survey conducted by the Research in European Paediatric Emergency Medicine network found that fever and risk stratification are research priorities. 6 Lillitos and colleagues assessed the performance of the Brighton and Children's Observation and Severity Tool...

Variation in low-value radiograph use for children in the emergency department: a cross-sectional study of administrative databases

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Modern Paediatric Emergency Department: Potential Improvements in Light of New Evidence

“…Recently published papers have outlined the increasing overcrowding in both adult [1] and paediatric [2] emergency departments. High level of stress exerted on emergency physicians, together with an environment full of multitasking and interruption, inevitably lead to elevated rate of task errors [3].…”

Modern Paediatric Emergency Department: Potential Improvements in Light of New Evidence

“…Recently published papers have outlined the increasing overcrowding in both adult [ 1 ] and paediatric [ 2 ] emergency departments. High levels of stress exerted on emergency physicians, together with an environment full of multitasking and interruption, inevitably lead to an elevated rate of task errors [ 3 ].…”