Emergency department crowding and thrombolysis delays in acute myocardial infarction

Schull, Michael J.; Vermeulen, Marian J.; Slaughter, Graham; Morrison, Laurie J.; Daly, Paul

doi:10.1016/j.annemergmed.2004.05.004

Cited by 362 publications

(209 citation statements)

References 30 publications

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“…This last point is supported by research showing that for patients with suspected myocardial infarctions, time to thrombolysis was longer during periods of emergency department crowding (Schull et al 2004).…”

Section: Emergency Department (Ed) Overcrowding Is a Growing Problem supporting

confidence: 54%

The Impact of Ambulance Diversion on Heart Attack Deaths

Yankovic

Glied²,

Green

et al. 2010

INQUIRY

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Hospital ambulance diversions are prevalent and increasing nationwide as emergency departments experience growing congestion. Using negative binomial regressions, this paper links the number of acute myocardial infarction (AMI) deaths to the level and extent of diversion in the five boroughs of New York City. The results indicate that both high levels of ambulance diversion and simultaneous diversion across hospitals are associated with increasing numbers of deaths from AMI.

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Section: Emergency Department (Ed) Overcrowding Is a Growing Problem supporting

confidence: 54%

The Impact of Ambulance Diversion on Heart Attack Deaths

Yankovic

Glied²,

Green

et al. 2010

INQUIRY

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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.…”

Section: Discussionmentioning

confidence: 99%

“…Numerous studies have demonstrated adverse effects of ED crowding, both on processes of care [1][2][3][4] and on important patient outcomes, including mortality. [5][6][7][8][9] One policy approach, which has been undertaken in several countries and several Canadian provinces, is to establish benchmarks for maximum ED length of stay (LOS), commonly known as ED LOS benchmarks.…”

Section: Introductionmentioning

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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“…EDOC is associated with adverse outcomes as the result of delays in treatment of patients with cardiac presentations, pain, and pneumonia, to name a few. [16][17][18][19] Although solutions to improve EDOC may be expected to and often do reduce OD, 20 it is possible that OD may independently contribute to these outcomes. Cooney et al stated that, although patient-level consequences of OD have not been well studied, OD may exacerbate EDOC-related impacts on clinical outcomes, such as poor pain control, delayed time to antibiotics, and increased morbidity and mortality.…”

Section: Edoc Initiatives and Impacts-where Are We Now?mentioning

confidence: 99%

Transfer of care and offload delay: continued resistance or integrative thinking?

Schwartz

2015

CJEM

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The disciplines of paramedicine and emergency medicine have evolved synchronously over the past four decades, linked by emergency physicians with expertise in prehospital care. Ambulance offload delay (OD) is an inevitable consequence of emergency department overcrowding (EDOC) and compromises the care of the patient on the ambulance stretcher in the emergency department (ED), as well as paramedic emergency medical service response in the community. Efforts to define transfer of care from paramedics to ED staff with a view to reducing offload time have met with resistance from both sides with different agendas. These include the need to return paramedics to serve the community versus the lack of ED capacity to manage the patient. Innovative solutions to other system issues, such as rapid access to trauma teams, reducing door-to-needle time, and improving throughput in the ED to reduce EDOC, have been achieved by involving all stakeholders in an integrative thinking process. Only by addressing this issue in a similar integrative process will solutions to OD be realized. RÉSUMÉLe champ des soins paramédicaux et celui de la méde-cine d'urgence ont tous deux évolué au même rythme au cours des quarante dernières années, liés qu'ils sont par des urgentologues rompus aux soins préhospitaliers. Toutefois, les retards de déchargement des ambulances (RDA) sont une conséquence inévitable de l'encombrement des services d'urgence (SU), ce qui a pour effet de mettre en péril les soins aux patients couchés sur des civières d'ambulance au SU ainsi que les services médicaux d'urgence (SMU) fournis par les paramédicaux dans la collectivité. Les efforts visant à définir le concept de transfert des services de soins depuis les SMU au SU, dans l'optique de réduire le temps de déchargement, se heurtent à la résistance des deux parties du fait que les intervenants ont des points de vue différents; en effet, il est question, pour les uns, de la nécessité de renvoyer les ambulanciers paramédicaux afin qu'ils puissent répondre aux besoins de la collectivité; pour les autres, du manque de capacité des SU à traiter les patients. La participation de toutes les parties intéressées dans un processus de pensée globale a permis de trouver des solutions novatrices à d'autres problèmes systémiques tels que l'accès rapide aux équipes de traumatologie, la réduction du temps d'attente depuis l'arrivée jusqu'au moment de la ponction et l'amélioration de la capacité de traitement des patients au SU pour en diminuer l'encombrement; ce n'est que par un processus similaire de pensée globale que l'on trouvera des solutions au problème de RDA. HISTORICAL BACKGROUND-HOW DID WE GET HERE?In Canada, the development and evolution of the science and practice of paramedicine have paralleled those of emergency medicine (EM) over the last 4 decades. Paramedics with advanced skills, such as manual defibrillation and endotracheal intubation, began practicing on air and land ambulances in the 1970s, becoming more prevalent in the 1980s. The Royal College of Ph...

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Emergency department crowding and thrombolysis delays in acute myocardial infarction

Cited by 362 publications

References 30 publications

The Impact of Ambulance Diversion on Heart Attack Deaths

The Impact of Ambulance Diversion on Heart Attack Deaths

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

Transfer of care and offload delay: continued resistance or integrative thinking?

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