Emergency department crowding and mortality in 14 Swedish emergency departments, a cohort study leveraging the Swedish Emergency Registry (SVAR)

Ugglas, Björn af; Lindmarker, Per; Ekelund, Ulf; Djärv, Therese; Holzmann, Martin J.

doi:10.1371/journal.pone.0247881

Cited by 19 publications

(19 citation statements)

References 23 publications

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“…EDLOS, was defined as the time from arrival to the time of departure rounded to the nearest whole minute. All patients with an EDLOS that was 0 min or less were excluded ( n = 484 or 0.4%) as well as those with an EDLOS more than 48 h ( n = 24 or 0.02%) due to likely erroneous values 19 . Patients were categorized into having either a long EDLOS (≥6 h) or a normal EDLOS (<6 h).…”

Section: Methodsmentioning

confidence: 99%

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Socioeconomic status is associated with process times in the emergency department for patients with chest pain

et al. 2023

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ObjectiveEmergency department length of stay (EDLOS) is linked to crowding and patient outcomes whereas worse prognosis in low socioeconomic status remains poorly understood. We studied whether income was associated with ED process times among patients with chest pain.MethodsThis was a registry‐based cohort study on 124,980 patients arriving at 14 Swedish EDs between 2015 and 2019 with chest pain as their chief complaint. Individual‐level sociodemographic and clinical data were linked from multiple national registries. The associations between disposable income quintiles, whether the time to physician assessment exceeded triage priority recommendations as well as EDLOS were evaluated using crude and multivariable regression models adjusted for age, gender, sociodemographic variables, and ED‐management circumstances.ResultsPatients with the lowest income were more likely to be assessed by physician later than triage recommendations (crude odds ratio [OR] 1.25 (95% confidence interval [CI] 1.20–1.29) and have an EDLOS exceeding 6 h (crude OR 1.22 (95% CI 1.17–1.27). Among patients subsequently diagnosed with major adverse cardiac events, patients with the lowest income were more likely to be assessed by a physician later than triage recommendations, crude OR 1.19 (95% CI 1.02–1.40). In the fully adjusted model, the average EDLOS was 13 min (5.6%) longer among patients in the lowest income quintile, 4:11 [h:min], (95% CI 4:08–4:13), compared to patients in the highest income quintile, 3:58 (95% CI 3:56–4:00).ConclusionsAmong ED chest pain patients, low income was associated with longer time to physician than recommended by triage and longer EDLOS. Longer process times may have a negative impact due to crowding in the ED and delay diagnosis and timely treatment of the individual patient.

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Section: Methodsmentioning

confidence: 99%

“…This was a retrospective cohort study in a tax-financed health care system based on the national quality register of EDs in Sweden, SVenska AkutvårdsRegistret (SVAR). 19…”

Section: Study Design and Settingmentioning

confidence: 99%

Socioeconomic status is associated with process times in the emergency department for patients with chest pain

et al. 2023

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“…Transporting all patients to ED naturally would entail a zero misclassification rate regarding EMS referrals to non-hospital care. However, such an approach would result in an increase of unnecessary EMS transports to the ED, an increased ED attendance resulting in ED crowding and thus a threat to patient safety [ 4 ]. Furthermore, allocated ambulances with non-emergent patients with conditions that could be managed in primary care could also be considered a suboptimal use of EMS resources.…”

Section: Main Textmentioning

confidence: 99%

“…It is considered to be an appropriate response to patients whose needs can be met at a lower level of care [ 3 ]. ED crowding has also been associated with increased short-term mortality and negative effects on the system and on the patient [ 4 – 6 ]. Decision-making at the scene has also been shown to reduce emergency admission rates [ 7 ].…”

Section: Introductionmentioning

confidence: 99%

Suboptimal prehospital decision- making for referral to alternative levels of care – frequency, measurement, acceptance rate and room for improvement

et al. 2022

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Background The emergency medical services (EMS) have undergone dramatic changes during the past few decades. Increased utilisation, changes in care-seeking behaviour and competence among EMS clinicians have given rise to a shift in EMS strategies in many countries. From transport to the emergency department to at the scene deciding on the most appropriate level of care and mode of transport. Among the non-conveyed patients some may suffer from “time-sensitive conditions” delaying diagnosis and treatment. Thus, four questions arise: How often are time-sensitive cases referred to primary care or self-care advice? How can we measure and define the level of inappropriate clinical decision-making? What is acceptable? How to increase patient safety? Main text To what extent time-sensitive cases are non-conveyed varies. About 5–25% of referred patients visit the emergency department within 72 hours, 5% are hospitalised, 1–3% are reported to have a time-sensitive condition and seven-day mortality rates range from 0.3 to 6%. The level of inappropriate clinical decision-making can be measured using surrogate measures such as emergency department attendances, hospitalisation and short-term mortality. These measures do not reveal time-sensitive conditions. Defining a scoring system may be one alternative, where misclassifications of time-sensitive cases are rated based on how severely they affected patient outcome. In terms of what is acceptable there is no general agreement. Although a zero-vision approach does not seem to be realistic unless under-triage is split into different levels of severity with zero-vision in the most severe categories. There are several ways to reduce the risk of misclassifications. Implementation of support systems for decision-making using machine learning to improve the initial assessment is one approach. Using a trigger tool to identify adverse events is another. Conclusion A substantial number of patients are non-conveyed, including a small portion with time-sensitive conditions. This poses a threat to patient safety. No general agreement on how to define and measure the extent of such EMS referrals and no agreement of what is acceptable exists, but we conclude an overall zero-vision is not realistic. Developing specific tools supporting decision making regarding EMS referral may be one way to reduce misclassification rates.

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“…Care in a specialized stroke unit is further associated with improvements in patient outcomes ( 3 ). A high bed occupancy rate (BOR) has been associated with increased admission threshold in emergency departments, and in some studies, it has also been associated with increased mortality ( 4 – 7 ). At the stroke unit, a high BOR might be associated with reduced quality of stroke care and a lower likelihood of direct admission to the stroke unit ( 8 ).…”

Section: Introductionmentioning

confidence: 99%

Stressed systems: Stroke unit bed occupancy and impact on reperfusion therapy in acute ischemic stroke

2023

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ObjectivesWe observed a decrease in the number of patients who were offered reperfusion therapy. We aimed to investigate if whether hospital system pressure measured as the percentage of stroke bed occupancy influenced decisions on treatment and disposition.DesignData from a regional quality of stroke care database were obtained and linked to the organizational data monitoring of the hourly inpatient stroke bed occupancy rate. Logistic regression was used to analyze the relationship.ResultsA total of 15,025 admissions were included from 1 January 2019 to 24 August 2022. Of these, 5,659 (38%) had an acute ischemic stroke. The rates of reperfusion therapy treatment were the highest in 2019 (36.2%) and 2020 (34.1%) and declined afterward (30.0% in 2021). In the logistic regression analysis, an occupancy rate of ≥85% in the hour of the first admission was associated with reduced odds of admission at the stroke unit within 3 h from the symptom onset [adjusted odds ratio: 0.80, 95% confidence interval: (0.71–0.90), p < 0.001] and a reduced odds of receiving reperfusion therapy (adjusted odds ratio: 0.83 (0.73–0.95), p = 0.007).ConclusionAn increased bed occupancy level in the hour of the first hospital admission for stroke patients was strongly associated with decreased odds of receiving reperfusion therapy.

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Emergency department crowding and mortality in 14 Swedish emergency departments, a cohort study leveraging the Swedish Emergency Registry (SVAR)

Cited by 19 publications

References 23 publications

Socioeconomic status is associated with process times in the emergency department for patients with chest pain

Socioeconomic status is associated with process times in the emergency department for patients with chest pain

Suboptimal prehospital decision- making for referral to alternative levels of care – frequency, measurement, acceptance rate and room for improvement

Stressed systems: Stroke unit bed occupancy and impact on reperfusion therapy in acute ischemic stroke

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