Objectives: Emergency department (ED) crowding is a major problem across the world. Studies investigating the association between crowding and mortality are many, but the quality is inconsistent and there are very few large, high-quality multicenter studies that are properly designed to deal with confounding due to case mix. The aim of this study is to investigate the association between ED crowding and 30-day mortality. Methods: We conducted an observational cohort study at all 7 EDs in Stockholm Region, Sweden 2012-2016. The crowding exposure was defined as the mean hourly ED census during the shift that the exposed patient arrived, divided with the expected ED census for this shift. The expected ED census was estimated using a separate linear model for each hospital with year and shift as predictors. The exposure was categorized in 3 groups: reference (lowest 75% of observations), moderate (75%-95% of observations), and high (highest 5% of observations). Hazard ratios (HR) for all-cause mortality within 30 days were estimated with a Cox proportional hazards model. The model was adjusted for age, sex, triage priority, arrival hour, weekend, arrival mode, chief complaint, number of prior hospital admissions, and comorbidities. Results: 884,228 patients who visited the ED 2,252,656 times were included in the analysis. The estimated HR (95% confidence interval) for death within 30-days was 1.00 (0.97-1.03) in crowding category 75%-95% and 1.08 (1.03-1.14) in the 95%-100% category. Conclusions: In a large cohort study including 7 EDs in Stockholm Region, Sweden we identified a significant association between high levels of ED crowding and increased 30-day mortality.
Objectives
COVID-19 presents challenges to the emergency care system that could lead to emergency department (ED) crowding. The Huddinge site at the Karolinska university hospital (KH) responded through a rapid transformation of inpatient care capacity together with changing working methods in the ED. The aim is to describe the KH response to the COVID-19 crisis, and how ED crowding, and important input, throughput and output factors for ED crowding developed at KH during a 30-day baseline period followed by the first 60 days of the COVID-19 outbreak in Stockholm Region.
Methods
Different phases in the development of the crisis were described and identified retrospectively based on major events that changed the conditions for the ED. Results were presented for each phase separately. The outcome ED length of stay (ED LOS) was calculated with mean and 95% confidence intervals. Input, throughput, output and demographic factors were described using distributions, proportions and means. Pearson correlation between ED LOS and emergency ward occupancy by phase was estimated with 95% confidence interval.
Results
As new working methods were introduced between phase 2 and 3, ED LOS declined from mean (95% CI) 386 (373–399) minutes to 307 (297–317). Imaging proportion was reduced from 29 to 18% and admission rate increased from 34 to 43%. Correlation (95% CI) between emergency ward occupancy and ED LOS by phase was 0.94 (0.55–0.99).
Conclusions
It is possible to avoid ED crowding, even during extreme and quickly changing conditions by leveraging previously known input, throughput and output factors. One key factor was the change in working methods in the ED with higher competence, less diagnostics and increased focus on rapid clinical admission decisions. Another important factor was the reduction in bed occupancy in emergency wards that enabled a timely admission to inpatient care. A key limitation was the retrospective study design.
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