The impact of ED crowding on early interventions and mortality in patients with severe sepsis

Gaieski, David F.; Agarwal, Anish K.; Mikkelsen, Mark E.; Drumheller, Byron C.; Sante, S. Cham; Shofer, Frances S.; Goyal, Munish; Pines, Jesse M.

doi:10.1016/j.ajem.2017.01.061

Cited by 110 publications

(97 citation statements)

References 28 publications

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“…Therefore, is anticipated that patients with very urgent symptoms and deranged vital parameters have a high mortality [32], in the present study reflected by a high mortality in patients with triage priority 1. It has been shown that long ED-LOS is harmful for patients with high degree of medical urgency (high triage priority), as for example for patients with non-ST-segment-elevation myocardial infarction [33] or for patients with sepsis [34]. We were not able to find any association between increased mortality and increased ED-LOS in patient with triage priority 1, instead, a negative association was observed.…”

Section: Discussioncontrasting

confidence: 73%

The association between length of stay in the emergency department and short term mortality

Wessman

Ärnlöv

Carlsson

et al. 2020

Preprint

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Background: The detrimental effects of increased length of stay at the emergency department (ED-LOS) for patient outcome have been sparsely studied in the Swedish setting. Our aim was to further explore the association between ED-LOS and short term mortality in patients admitted to the EDs of two large University hospitals in Sweden. Methods: All adult patients (> 18 years) visiting the ED at the Karolinska University Hospital, Sweden, from 1/1/2010 to 1/1/2015 (n=639 385) were retrospectively included. Logistic regression analysis was used to determine association between ED-LOS and 7 and 30-day mortality rates. All patients were triaged according to the RETTS-A into different levels of medical urgency and subsequently separated into five quintiles of ED-LOS. Results: We observed that prolonged ED-LOS was associated with increased mortality for patients with lowest triage priority (risk estimates for 30-day mortality were OR 1.49 (CI 95% 1.20-1.85) for patients with triage priority group 4 and the highest quintile of ED-LOS. No such association was observed in patients with the highest triage priority group and in patients admitted to in-hospital care. Conclusion : Our data suggest that increased ED-LOS could be associated with slightly increased short term mortality in patients with lower clinical urgency and dismissed from the ED but that this does not include patients admitted to in-hospital care.

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Section: Discussioncontrasting

confidence: 73%

The association between length of stay in the emergency department and short term mortality

Wessman

Ärnlöv

Carlsson

et al. 2020

Preprint

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“…[8,9] These potential dangers can be particularly detrimental for patients who needed time-critical interventions to effectively treat emergency conditions such as acute stroke, [4] acute respiratory failure, [10] and septic shock. [11] Cardiac arrest is a critical situation requiring prompt intervention and continues to be a major public health burden. [12,13] A previous study found that quality of out-of-hospital cardiac arrest (OHCA) was not associated with overcrowding because emergency medical services could alert the ED cardiopulmonary resuscitation (CPR) team of incoming OHCA patients, allowing time for the team to activate.…”

Section: Introductionmentioning

confidence: 99%

Maximum emergency department overcrowding is correlated with occurrence of unexpected cardiac arrest

Kim

Bae²,

Sohn

et al. 2020

Preprint

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Background Emergency department overcrowding negatively impacts critically ill patients and could lead to the occurrence of cardiac arrest. However, associations between emergency department crowding and occurrence of both in-hospital cardiac arrest and out-of-hospital cardiac arrest have not been thoroughly investigated. This study aimed to evaluate the correlation between emergency department occupancy rates and incidence of in-hospital and out-of-hospital cardiac arrest. Methods A single-center, observational, registry-based cohort study was performed including all consecutive adult, non-traumatic cardiac arrest patients between January 2014 and June 2017. We used emergency department occupancy rates as a crowding index at time of presentation time of cardiac arrest and at the time of maximum crowding, and the average crowding rate for the duration of emergency department stay for each patient. To calculate incidence rate, we divided the number of arrest cases for each emergency department occupancy period by accumulated time. The primary outcome is association between the incidence of in-hospital cardiac arrest and out-of-hospital cardiac arrest and emergency department occupancy rates. Results During the study period, 629 adult, non-traumatic cardiac arrest patients were enrolled in our registry. Among these, 187 patients experienced in-hospital cardiac arrest and 442 patients had out-of-hospital cardiac arrest. In-hospital cardiac arrest patients compared to out-of-hospital cardiac arrest patients had a significantly higher return of spontaneous circulation rates (16.5% vs. 4.8%; P < .01) and better neurologic outcomes at discharge (cerebral performance category scales 4.7 vs. 4.0; P < .01). Emergency department occupancy rates were positively correlated with in-hospital cardiac arrest occurrence. Moreover, maximum emergency department occupancy in the critical zone had the strongest positive correlation with in-hospital cardiac arrest occurrence (Spearman rank correlation ρ = 1.0, P < .01). Out-of-hospital cardiac arrest incidence was negatively correlated with emergency department occupancy (ρ = -0.79, P = .04). Conclusion Maximum emergency department occupancy was strongly associated with in-hospital cardiac arrest occurrence, while occupancy rate was negatively correlated with out-of-hospital cardiac arrest incidence.

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“…1 Although ED crowding is recognized as a public health crisis, it persists. 1 ED crowding is associated with longer wait times to be seen, increasing number of patients who leave without being seen (LWBS), poorer access, 2,3 worse patient experience, 4-10 decreased quality of care, 8,[11][12][13][14][15][16][17][18][19] and adverse consequences on health system finances. 20 Several strategies have been proposed to decrease LWBS rates and improve ED throughput.…”

Section: Introductionmentioning

confidence: 99%

Impact of Emergency Department Tele‐intake on Left Without Being Seen and Throughput Metrics

Joshi

Randolph

Chang

et al. 2019

Academic Emergency Medicine

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Objectives More than 2 million patients present to a U.S. emergency department (ED) annually and leave without being seen (LWBS) due to delays in initiating care. We evaluated whether tele‐intake at the time of presentation would reduce LWBS rates and ED throughput measures. Methods We conducted a before‐and‐after study at an urban community hospital. The intervention was use of a tele‐intake physician to triage patients from 11 am to 6 pm, 7 days per week. Tele‐intake providers performed a triage history and physical examination, documented findings, and initiated orders in the medical record. We assessed the impact of this program using the domains of the National Quality Forum framework evaluating access, provider experience, and effectiveness of care. The main outcome was 24‐hour LWBS rate. Secondary outcomes were overall door to provider and door to disposition times, left without treatment complete (LWTC), left against medical advice (AMA), left without treatment (LWOT), and physician experience. We compared the 6‐month tele‐intake period to the same period from the prior year (October 1 to April 1, 2017 vs. 2016). Additionally, we conducted a survey of our physicians to assess their experience with the program. Results Total ED volume was similar in the before and after periods (19,892 patients vs. 19,646 patients). The 24‐hour LWBS rate was reduced from 2.30% (95% confidence interval [CI] = 2.0% to 2.5%) to 1.69% (95% CI = 1.51% to 1.87%; p < 0.001). Overall door to provider time decreased (median = 19 [interquartile range {IQR} = 9 to 38] minutes vs. 16.2 [IQR = 7.8 to 34.3] minutes; p < 0.001), but ED length of stay for all patients (defined as door in to door out time for all patients) minimally increased (median = 184 [IQR = 100 to 292] minutes vs. 184.3 [IQR = 104.4 to 300] minutes; p < 0.001). There was an increase in door to discharge times (median = 146 [IQR = 83 to 231] minutes vs. 148 [IQR = 88.2 to 233.6] minutes; p < 0.001) and door to admit times (median = 330 [IQR = 253 to 432] minutes vs. 357.6 [IQR = 260.3 to 514.5] minutes; p < 0.001). We saw an increase in LWTC (0.59% [95% CI = 0.49% to 0.70%] vs. 1.1% [95% CI = 0.9% to 1.2%]; p < 0.001), but no change in AMA (1.4% [95% CI = 1.2% to 1.6%] vs. 1.6% [95% CI = 1.4% to 1.78%]; p = 0.21) or LWOT (4.3% [95% CI = 4.1% to 4.6%] vs. 4.4% [95% CI = 4.1% to 4.7%]; p = 0.7). Tele‐intake providers thought tele‐intake added value (12/15, 80%) and allowed them to effectively address medical problems (14/15, 95%), but only (10/15, 67%) thought that it was as good as in‐person triage. Of the receiving physicians, most agreed with statements that tele‐intake did not interfere with care (19/22, 86%), helped complement care (19/21, 90%), and gave the patient a better experience (19/22, 86%). Conclusions Remote tele‐intake provided in an urban community hospital ED reduced LWBS and time to provider but increased LWTC rates and had no impact on LWOT.

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The impact of ED crowding on early interventions and mortality in patients with severe sepsis

Cited by 110 publications

References 28 publications

The association between length of stay in the emergency department and short term mortality

The association between length of stay in the emergency department and short term mortality

Maximum emergency department overcrowding is correlated with occurrence of unexpected cardiac arrest

Impact of Emergency Department Tele‐intake on Left Without Being Seen and Throughput Metrics

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