Emergency Department Crowding and Decreased Quality of Pain Care

Hwang, Ula; Richardson, Lynne D.; Livote, Elayne; Harris, Ben; Spencer, Natasha; Morrison, R. Sean

doi:10.1111/j.1553-2712.2008.00267.x

Cited by 135 publications

(97 citation statements)

References 38 publications

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“…Prolonged ED LOS can lead to delays in diagnosis and/or treatment for specific conditions, such as timely administration of antibiotics for pneumonia 1,34 and febrile neonates, 35 reperfusion for acute myocardial infarction patients, 2,34 orders and completion of computed tomography scans for stroke, 36 medication orders for asthma, 37 and administration of analgesics for hip fracture and other painful conditions. 3,4,38,39 Crowding in the ED may also affect disposition decisions and has been associated with a lower likelihood of hospital admission in a study of pediatric ED patients with asthma or gastroenteritis. 40 The current study adds to this prior work by demonstrating an association with serious adverse events when ED crowding is expressed as shift-level performance on Ontario's ED LOS benchmarks.…”

Section: Discussionmentioning

confidence: 99%

Better performance on length-of-stay benchmarks associated with reduced risk following emergency department discharge: an observational cohort study

Schull

Vermeulen²,

Guttmann

et al. 2015

CJEM

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Introduction: Emergency department (ED) crowding is associated with adverse outcomes. Several jurisdictions have established benchmarks and targets for length-of-stay (LOS) to reduce crowding. An evaluation has been conducted on whether performance on Ontario's ED LOS benchmarks is associated with reduced risk of death or hospitalization. Methods: A retrospective cohort study of discharged ED patients was conducted using population-based administrative data from Ontario (April 2008 to February 2012). For each ED visit, the proportion of patients seen during the same shift that met ED LOS benchmarks was determined. Performance was categorized as <80%, 80% to <90%, 90% to <95%, and 95%-100% of same-shift ED patients meeting the benchmark. Logistic regression models analysed the association between performance on ED LOS benchmarks and 7-day death or hospitalization, controlled for patient and ED characteristics and stratified by patient acuity. Results: From 122 EDs, 2,295,256 high-acuity and 1,626,629 low-acuity visits resulting in discharge were included. Deaths and hospitalizations within 7 days totalled 1,429 (0.062%) and 49,771 (2.2%) among high-acuity, and 220 (0.014%) and 9,005 (0.55%) among low-acuity patients, respectively. Adverse outcomes generally increased among patients seen during shifts when a lower proportion of ED patients met ED LOS benchmarks. The adjusted odds ratios (and 95% confidence intervals) among high-and low-acuity patients seen on shifts when <80% met ED benchmarks (compared with ≥95%) were, respectively, 1.32 (1.05-1.67) and 1.84 (1.21-2.81) for death, and 1.13 (1.08-1.17) and 1.40 (1.31-1.49) for hospitalization. Conclusions: Better performance on Ontario's ED LOS benchmarks for each shift is associated with a 10%-45% relative reduction in the odds of death or admission 7 days after ED discharge.

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Section: Discussionmentioning

confidence: 99%

Better performance on length-of-stay benchmarks associated with reduced risk following emergency department discharge: an observational cohort study

Schull

Vermeulen²,

Guttmann

et al. 2015

CJEM

View full text Add to dashboard Cite

show abstract

“…Researchers have studied the social context of the ED environment and the potential effect on the management of pain with a recent emphasis on effect of ED overcrowding (Bernstein et al, 2009;Duignan & Dunn, 2009;Hwang, Richardson, Sonuyi, & Morrison, 2006;Hwang et al, 2008;Pines, Shofer, Isserman, Abbuhl, & Mills, 2010;Russo, 2010;Tanabe, 1996;Tanabe & Buschmann, 1999). Of those studies located, three quantitative studies measured ED nurses' perceived barriers to general pain management (Duignan & Dunn, 2009;Tanabe, 1996;Tanabe & Buschmann, 1999), four studies examined the effect of ED crowding on quality of pain care, analgesia in patients with back pain, the management of pain in older adults with hip fracture, and patients who presented at triage with severe pain (Hwang et al, 2006;Hwang et al, 2008;Pines & Hollander, 2008;Pines et al, 2010).…”

Section: Environmental Issues and Policies In The Edmentioning

confidence: 99%

“…Of those studies located, three quantitative studies measured ED nurses' perceived barriers to general pain management (Duignan & Dunn, 2009;Tanabe, 1996;Tanabe & Buschmann, 1999), four studies examined the effect of ED crowding on quality of pain care, analgesia in patients with back pain, the management of pain in older adults with hip fracture, and patients who presented at triage with severe pain (Hwang et al, 2006;Hwang et al, 2008;Pines & Hollander, 2008;Pines et al, 2010). One qualitative study was located that identified the theme things that hinder decision-making for pediatric pain (Russo, 2010).…”

Section: Environmental Issues and Policies In The Edmentioning

confidence: 99%

An Ethnography of the Culture of Pain in a Non-Pediatric Emergency Department

Cummings¹

2013

Journal of Pediatric Health Care

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Rationale for the Study: Despite the exponential growth in pharmacological and nonpharmacological methods for the treatment of pediatric procedural pain there remains a gap between available interventions and actual practice in the emergency department clinical setting. Researchers have recommended the examination of unit culture since culture is proposed to be a major factor that affects the implementation of pain management practices. Method:Ethnography was employed to gain access to the beliefs and practices of healthcare participants in a Northeastern non-pediatric emergency department. Data were collected for 5 months with over 100 hours of observation. Six key informants were interviewed and 44 pediatric procedural interactions with 27 healthcare providers during the treatment of children two to eight years of age undergoing procedures were observed.Other information gathered included documents from the institution, and pain related information from the patient's medical record. All interviews were recorded and transcribed verbatim. Data were managed using the Ethnograph 6.0 and analyzed using the procedure developed by Leininger and McFarland (2006). Results:Seven major themes with categories were discovered that included assessment, ii procedural pain, treatment of pain, communication related to comfort, fragmentation of care in the emergency department, healthcare provider attitudes, and environmental issues and policies. Conclusion:The results of this study suggest that practice environment of the emergency department and organizational culture exerted a significant degree of influence over healthcare providers' pediatric pain management practices. Nurses' did not use pain measurement tools as they were intended to be used and instead improvised measurement by observing the child's behavior. The management of children during painful procedures consisted of an array of behaviors and practices. The use of physical restraint during painful procedures was a common practice. Participants continue to hold many assumptions and misconceptions about pediatric pain assessment and management. The findings of this study provide insight to the everyday practice of emergency department healthcare providers for pediatric pain in a non-pediatric setting.iii Acknowledgments and Dedication

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“…They are also medical homes for many uninsured people and have been shown to reduce non-emergent visits to emergency departments [24][25][26]. While free clinics were likely never considered as the ACA was drafted, this act has already begun to impact their plans; therefore, states should anticipate meaningful and unanticipated consequences to the safety-net system for the uninsured population as a whole.…”

mentioning

confidence: 99%