Study objective We evaluate recent trends in emergency department (ED) crowding and its potential causes by analyzing ED occupancy, a proxy measure for ED crowding. Methods We analyzed data from the ...annual National Hospital Ambulatory Medical Care Surveys from 2001 to 2008. The surveys abstract patient records from a national sample of hospital EDs to generate nationally representative estimates of visits. We used time of ED arrival and length of ED visit to calculate mean and hourly ED occupancy. Results During the 8-year study period, the number of ED visits increased by 1.9% per year (95% confidence interval 1.2% to 2.5%), a rate 60% faster than population growth. Mean occupancy increased even more rapidly, at 3.1% per year (95% confidence interval 2.3% to 3.8%), or 27% during the 8 study years. Among potential factors associated with crowding, the use of advanced imaging increased most, by 140%. But advanced imaging had a smaller effect on the occupancy trend than other more common throughput factors, such as the use of intravenous fluids and blood tests, the performance of any clinical procedure, and the mention of 2 or more medications. Of patient characteristics, Medicare payer status and the age group 45 to 64 years accounted for small disproportionate increases in occupancy. Conclusion Despite repeated calls for action, ED crowding is getting worse. Sociodemographic changes account for some of the increase, but practice intensity is the principal factor driving increasing occupancy levels. Although hospital admission generated longer ED stays than any other factor, it did not influence the steep trend in occupancy.
We determine how pediatric emergency department (ED) visits changed during the COVID-19 pandemic in a large sample of U.S. EDs.
Using retrospective data from January–June 2020, compared to a similar ...2019 period, we calculated weekly 2020–2019 ratios of Non-COVID-19 ED visits for adults and children (age 18 years or less) by age range. Outcomes were pediatric ED visit rates before and after the onset of pandemic, by age, disposition, and diagnosis.
We included data from 2,213,828 visits to 144 EDs and 4 urgent care centers in 18 U.S. states, including 7 EDs in children's hospitals. During the pandemic period, adult non-COVID-19 visits declined to 60% of 2019 volumes and then partially recovered but remained below 2019 levels through June 2020. Pediatric visits declined even more sharply, with peak declines through the week of April 15 of 74% for children age < 10 years and 67% for 14–17 year. Visits recovered by June to 72% for children age 14–17, but to only 50% of 2019 levels for children < age 10 years. Declines were seen across all ED types and locations, and across all diagnoses, with an especially sharp decline in non-COVID-19 communicable diseases. During the pandemic period, there was 22% decline in common serious pediatric conditions, including appendicitis.
Pediatric ED visits fell more sharply than adult ED visits during the COVID-19 pandemic, and remained depressed through June 2020, especially for younger children. Declines were also seen for serious conditions, suggesting that parents may have avoided necessary care for their children.
Emergency department (ED) crowding and patient boarding are associated with increased mortality and decreased patient satisfaction. This study uses a positive deviance methodology to identify ...strategies among high-performing, low-performing, and high-performance improving hospitals to reduce ED crowding.
In this mixed-methods comparative case study, we purposively selected and recruited hospitals that were within the top and bottom 5% of Centers for Medicare & Medicaid Services case-mix-adjusted ED length of stay and boarding times for admitted patients for 2012. We also recruited hospitals that showed the highest performance improvement in metrics between 2012 and 2013. Interviews were conducted with 60 key leaders (physicians, nurses, quality improvement specialists, and administrators).
We engaged 4 high-performing, 4 low-performing, and 4 high-performing improving hospitals, matched on hospital characteristics including geographic designation (urban versus rural), region, hospital occupancy, and ED volume. Across all hospitals, ED crowding was recognized as a hospitalwide issue. The strategies for addressing ED crowding varied widely. No specific interventions were associated with performance in length-of-stay metrics. The presence of 4 organizational domains was associated with hospital performance: executive leadership involvement, hospitalwide coordinated strategies, data-driven management, and performance accountability.
There are organizational characteristics associated with ED decreased length of stay. Specific interventions targeted to reduce ED crowding were more likely to be successfully executed at hospitals with these characteristics. These organizational domains represent identifiable and actionable changes that other hospitals may incorporate to build awareness of ED crowding.
Study objective We study the impact of emergency department (ED) crowding on delays in treatment and nontreatment for patients with severe pain. Methods We performed a retrospective cohort study of ...all patients presenting with severe pain to an inner-city, teaching ED during 17 months. Poor care was defined by 3 outcomes: not receiving treatment with pain medication while in the ED, a delay (>1 hour) from triage to first pain medication, and a delay (>1 hour) from room placement to first pain medication. Three validated crowding measures were assigned to each patient at triage. Logistic regression was used to test the association between crowding and outcomes. Results In 13,758 patients with severe pain, the mean age was 39 years (SD 16 years), 73% were black, and 64% were female patients. Half (49%) of the patients received pain medication. Of those treated, 3,965 (59%) experienced delays in treatment from triage and 1,319 (20%) experienced delays from time of room placement. After controlling for factors associated with the ED treatment of pain (race, sex, severity, and older age), nontreatment was independently associated with waiting room number (odds ratio OR 1.03 for each additional waiting patient; 95% confidence interval CI 1.02 to 1.03) and occupancy rate (OR 1.01 for each 10% increase in occupancy; 95% CI 0.99 to 1.04). Increasing waiting room number and occupancy rate also independently predicted delays in pain medication from triage (OR 1.05 for each waiting patient, 95% CI 1.04 to 1.06; OR 1.18 for each 10% increase in occupancy; 95% CI 1.15 to 1.21) and delay in pain medication from room placement (OR 1.02 for each waiting patient, 95% CI 1.01 to 1.03; OR 1.06 for each 10% increase in occupancy, 95% CI 1.04 to 1.08). Conclusion ED crowding is associated with poor quality of care in patients with severe pain, with respect to total lack of treatment and delay until treatment.
Background: Computed tomography (CT) and ultrasound (US) are used in emergency departments (ED) to aid in the diagnosis of patients with abdominal pain. Objectives: To describe trends in CT and US ...use in United States EDs and determine if higher test use is associated with higher detection rates for intra-abdominal illnesses commonly detected on CT and US and lower hospital admission rates. Research Design: Retrospective study using the 2001 to 2005 National Hospital Ambulatory Medical Care Survey, a nationally representative sample of ED encounters. Subjects: ED patients presenting with abdominal pain. Measures: Annual rates of and trends in CT and US use, rates of intra-abdominal illnesses, hospital admission rate. Results: Abdominal pain visits accounted for 38.8 million encounters; 17.8% received a CT and 11.7% received an US. CT use increased from 10.1% in 2001 to 22.5% in 2005 (P < 0.001). US use increased from 11.1% in 2001 to 13.6% in 2005 (P = 0.002). During the same period, detection rates for appendicitis, diverticulitis, and gall bladder disease did not increase and admission rates did not decrease. Conclusion: Despite a more than doubling in CT use and increases in US use, there was no increase in detection rates for appendicitis, diverticulitis, and gall bladder disease nor was there a reduction in admissions.
Costs of ED episodes of care in the United States Galarraga, Jessica E., MD, MPH; Pines, Jesse M., MD, MBA, MSCE
The American journal of emergency medicine,
03/2016, Letnik:
34, Številka:
3
Journal Article
Recenzirano
Abstract Background Emergency department (ED) care is a focus of cost reduction efforts. Costs for acute care originating in the ED, including outpatient and inpatient encounters (i.e. ED episodes), ...have not been estimated. Objective We estimate total US costs of ED episodes, potentially avoidable costs, and proportional costs of national health expenditures (NHEs). Methods We conducted a secondary analysis of 2010 data from the Medical Expenditure Panel Survey, National Hospital Ambulatory Medical Care Survey, and the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample. Outpatient ED encounters were categorized based on the New York University algorithm and admissions by ambulatory care–sensitive condition (ACSC) vs non-ACSC. Potentially avoidable encounters were nonemergent ED visits and ACSC hospital admissions. Using the Medical Expenditure Panel Survey, we determined mean per-visit payments for each visit type. Using the National Hospital Ambulatory Medical Care Survey and Nationwide Inpatient Sample, we estimated aggregate expenditures and proportional costs of NHE by visit category. Results Emergency department episodes of care accounted for $328.1 billion in payments in 2010. This represented 12.5% of NHE; ED admissions were 8.3% and outpatient ED care was 4.2%. Nonemergent outpatient visits were the most common, comprising 30.4% of ED episodes, and non-ACSC admissions were the most costly at $188.3 billion. Potentially avoidable encounters accounted for $64.4 billion, 19.6% of ED episodes, and 2.4% of NHE. Conclusions More than 1 in 10 health care dollars is spent on ED episodes of care. Of this, less than 1 in 5 dollars is potentially avoidable; therefore, efforts to reduce ED visits through improved primary care may have little impact on overall costs.
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