Evaluating the effect of emergency department crowding on triage destination

Abstract

BackgroundEmergency Department (ED) crowding has been studied for the last 20 years, yet many questions remain about its impact on patient care. In this study, we aimed to determine if ED crowding influenced patient triage destination and intensity of investigation, as well as rates of unscheduled returns to the ED. We focused on patients presenting with chest pain or shortness of breath, triaged as high acuity, and who were subsequently discharged home.MethodsThis pilot study was a health records review of 500 patients presenting to two urban tertiary care EDs with chest pain or shortness of breath, triaged as high acuity and subsequently discharged home. Data extracted included triage time, date, treatment area, time to physician initial assessment, investigations ordered, disposition, and return ED visits within 14 days. We defined ED crowding as ED occupancy greater than 1.5. Data were analyzed using descriptive statistics and the χ2 and Fisher exact tests.ResultsOver half of the patients, 260/500 (52.0%) presented during conditions of ED crowding. More patients were triaged to the non-monitored area of the ED during ED crowding (65/260 (25.0%) vs. 39/240 (16.3%) when not crowded, P = 0.02). During ED crowding, mean time to physician initial assessment was 132.0 minutes in the non-monitored area vs. 99.1 minutes in the monitored area, P <0.0001. When the ED was not crowded, mean time to physician initial assessment was 122.3 minutes in the non-monitored area vs. 67 minutes in the monitored area, P = 0.0003. Patients did not return to the ED more often when triaged during ED crowding: 24/260 (9.3%) vs. 29/240 (12.1%) when ED was not crowded (P = 0.31). Overall, when triaged to the non-monitored area of the ED, 44/396 (11.1%) patients returned, whereas in the monitored area 9/104 (8.7%) patients returned, P = 0.46.ConclusionsED crowding conditions appeared to influence triage destination in our ED leading to longer wait times for high acuity patients. This did not appear to lead to higher rates of return ED visits amongst discharged patients in this cohort. Further research is needed to determine whether these delays lead to adverse patient outcomes.

The relationship between emergency department crowding and outcome of referred critical patients from other hospitals

“…12 In O'Connor et al study, 52% were referred to the ED during peak hours. 10 In our study, the mortality rate was relatively higher than other similar studies, which may be due to including critical patients with higher mortality rate in our study. Moreover, poor treatment facilities could be another potential reason.…”

“…9 In O'Connor et al study 53.8% were men. 10 In another study, the mean age was 65 and 56.8% were men. 11 In Pines et al study, 57.0% were men with the mean ± SD age of 44 ± 17 years.…”

“…In another study, duration of physician initial assessment was 122.3 minutes in nonmonitoring beds. 10 In Pines study, duration of staying in ED was 10.8 hours. 12 In NasrEsfahani et al 13 and in Cha et al 14 studies, duration of staying in ED was 10.4 ± 5.5 and 8 hours, respectively.…”

Emergency severity index version 4 during the first year of implementation at an academic institution

“…[3] The effects of overcrowding in EDs has led to increased wait times and increased concerns that patient outcomes will suffer. [4][5][6][7] One study found that during crowded conditions, patients with higher acuity such as chest pain or shortness of breath had longer wait times and were inappropriately roomed in non-monitored ED beds. In fact, overcrowding has been associated with increased patient mortality, delayed antibiotic administration, delayed resuscitation efforts, and poor pain management.…”

“…In fact, overcrowding has been associated with increased patient mortality, delayed antibiotic administration, delayed resuscitation efforts, and poor pain management. [7] In order to maintain quality care for ED patients, a joint committee of the Emergency Nurses Association (ENA) and the American College of Emergency Physicians (ACEP) encouraged the use of the Emergency Severity Index (ESI). [8] It is the most widely used triage system in the United States and is becoming more widely used in other non English speaking countries.…”