The effects of unexpected changes in demand on the performance of emergency departments

Abstract

Crowding in emergency departments (EDs) is increasing in many health systems. Previous studies of the relationship between crowding and care quality are limited by the use of data from single hospitals, a focus on particular patient groups, a focus on a narrow set of quality measures, and use of crowding measures which induce bias from unobserved hospital and patient characteristics. Using data from 139 hospitals covering all major EDss in England, we measure crowding using quasi-exogenous variation in the volume of EDs attendances and examine its impacts on indicators of performance across the entire EDs care pathway. We exploit variations from expected volume estimated using high-dimensional fixed effects capturing hospital-specific variation in attendances by combinations of month and hour-of-the-week. Unexpected increases in attendance volume result in substantially longer waiting times, lower quantity and complexity of care, more patients choosing to leave without treatment, changes in referral and discharge decisions, but only small increases in reattendances and no increase in mortality. Causal bounds under potential omitted variable bias are narrow and exclude zero for the majority of outcomes. Results suggest that physician and patient responses may largely mitigate the impacts of demand increases on patient outcomes in the short-run. K E Y W O R D S attendance volume, crowding, emergency departments, physician behavior, quality of care 1 | INTRODUCTION Hospital departments providing emergency care are facing unprecedented pressures. In both the United States and the United Kingdom, the last decade has seen substantial increases in attendances at emergency departments (EDs; Trendwatch, 2015). In England, attendances at major EDs grew 24% between 2003/4 and 2018/19 and by 5.8% between September 2018 and September 2019 (NHS England, 2019b). Coupled with supply side pressures such as reductions in the number of inpatient beds and increased rates of patients facing delayed discharges (NHS England, 2017b; The King's This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Emergency department outcomes for patients experiencing homelessness in England: retrospective cross-sectional study

“…Descriptive features of the Type 1 ED attendances in this study are different to patients in the general population. Compared with a large sample of ED attendances in 2016/17, 25 a greater percentage of patients in our study left before treatment (15% vs. 4%), and arrived by ambulance (56% vs. 30%). A lower percentage of attendances in this study resulted in admission to hospital (22% vs. 28%).…”

“…Unplanned ED re-attendance within 7 days is an indicator of poor quality care. 25 We created a binary indicator for whether there was an unplanned follow-up attendance within 7 days of the initial attendance.…”

“… 24 Both percentages are significantly higher than for the general population. 25 A comparative study of ED attendances at a hospital in Dublin, Ireland, found that 40% of attendances by PEH resulted in leaving the ED before assessment, compared with 15% of attendances by housed persons. 14 …”

Quarterly Economic Commentary, Spring 2023

“…There is growing evidence that insufficient bed capacity and high bed occupancy rates are linked to higher patient mortality, poor in-hospital outcomes, and risks to hospital staff welfare (Keegan, 2010;Madsen et al, 2014;Bosque-Mercader and Siciliani, 2022). High bed occupancy also results in overcrowding on hospital corridors and in Emergency Departments (as regularly experienced in Ireland, particularly in Winter 2022/2023) (Morley et al, 2018;Turner et al, 2020). The 85 per cent average occupancy rate threshold has been adopted by the OECD and other systems as an upper average threshold for hospitals to aim for.…”

Spikes in demand for hospital transfusion services

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