What is the clinical evidence from this study?

Study design: Observational. Population: Emergency department visits (n=111529). Intervention: High ED occupancy vs. Non-high ED occupancy. Primary outcome: Hospital admission (OR 0.93, 95% CI 0.89-0.98).

January 30, 2019Open Access

Evaluating the impact of emergency department crowding on disposition patterns and outcomes of discharged patients

Key Result

High emergency department occupancy during disposition decisions decreased the odds of hospital admission (OR 0.93) without increasing the likelihood of 14-day return visits or subsequent hospitalizations.

Study Design

Type

Observational (n=111,529)

Multicenter

Structured PICO

Does high ED occupancy reduce the likelihood of hospital admission in adult ED patients?

Population

111,529 ED visits at an adult, urban, and academic tertiary care teaching hospital ED over a 20-month period between 2012 and 2014.

Intervention

Disposition decision made during a high occupancy hour (defined as the top decile of occupancy for that specific hour across all days).

Comparator

Disposition decision made during a non-high occupancy hour.

Outcome

Patient disposition (whether or not the patient was admitted or discharged).

ED crowding is associated with a reduced likelihood of hospital admission, without an increased likelihood of 14-day return ED visits or subsequent hospitalizations.

Main Result

Effect estimate: OR 0.93 (95% CI 0.89-0.98)

Limitations

Use of coded administrative data may affect quality and validity
Conducted at a single adult, academic, and urban ED, limiting generalizability
14-day return ED visits could be unrelated to the sentinel ED visit
Return ED visits to other hospitals were not captured
Admission/discharge time stamps may not accurately reflect when a disposition decision was actually made

Abstract

BACKGROUND: Crowding is a major challenge faced by EDs and is associated with poor outcomes. OBJECTIVES: Determine the effect of high ED occupancy on disposition decisions, return ED visits, and hospitalizations. METHODS: We conducted a retrospective analysis of electronic health records of patients evaluated at an adult, urban, and academic ED over 20 months between the years 2012 and 2014. Using a logistic regression model predicting admission, we obtained estimates of the effect of high occupancy on admission disposition, adjusted for key covariates. We then stratified the analysis based on the presence or absence of high boarder patient counts. RESULTS: Disposition decisions during a high occupancy hour decreased the odds of admission (OR = 0.93, 95% CI: 0.89, 0.98). Among those who were not admitted, high occupancy was not associated with increased odds of return in the combined (OR = 0.94, 95% CI: 0.87, 1.02), with-boarders (OR = 0.96, 95% CI: 0.86, 1.09), and no-boarders samples (OR = 0.93, 95% CI: 0.83, 1.04). Among those who were not admitted and who did return within 14 days, disposition during a high occupancy hour on the initial ED visit was not associated with a significant increased odds of hospitalization in the combined (OR = 1.04, 95% CI: 0.87, 1.24), the with-boarders (OR = 1.12, 95% CI: 0.87, 1.44), and the no-boarders samples (OR = 0.98, 95% CI: 0.77, 1.24). CONCLUSION: ED crowding was associated with reduced likelihood of hospitalization without increased likelihood of 2-week return ED visit or hospitalization. Furthermore, high occupancy disposition hours with high boarder patient counts were associated with decreased likelihood of hospitalization.

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