Sociodemographic Disparities in Queue Jumping for Emergency Department Care

Abstract

ImportanceEmergency department (ED) triage models are intended to queue patients for treatment. In the absence of higher acuity, patients of the same acuity should room in order of arrival.ObjectiveTo characterize disparities in ED care access as unexplained queue jumps (UQJ), or instances in which acuity and first come, first served principles are violated.Design, Setting, and ParticipantsRetrospective, cross-sectional study between July 2017 and February 2020. Participants were all ED patient arrivals at 2 EDs within a large Northeast health system. Data were analyzed from July to September 2022.ExposureUQJ was defined as a patient being placed in a treatment space ahead of a patient of higher acuity or of a same acuity patient who arrived earlier.Main Outcomes and MeasuresPrimary outcomes were odds of a UQJ and association with ED outcomes of hallway placement, leaving before treatment complete, escalation to higher level of care while awaiting inpatient bed placement, and 72-hour ED revisitation. Secondary analysis examined UQJs among high acuity ED arrivals. Regression models (zero-inflated Poisson and logistic regression) adjusted for patient demographics and ED operational variables at time of triage.ResultsOf 314 763 included study visits, 170 391 (54.1%) were female, the mean (SD) age was 50.46 (20.5) years, 132 813 (42.2%) patients were non-Hispanic White, 106 401 (33.8%) were non-Hispanic Black, and 66 465 (21.1%) were Hispanic or Latino. Overall, 90 698 (28.8%) patients experienced a queue jump, and 78 127 (24.8%) and 44 551 (14.2%) patients were passed over by a patient of the same acuity or lower acuity, respectively. A total of 52 959 (16.8%) and 23 897 (7.6%) patients received care ahead of a patient of the same acuity or higher acuity, respectively. Patient demographics including Medicaid insurance (incident rate ratio [IRR], 1.11; 95% CI, 1.07-1.14), Black non-Hispanic race (IRR, 1.05; 95% CI, 1.03-1.07), Hispanic or Latino ethnicity (IRR, 1.05; 95% CI, 1.02-1.08), and Spanish as primary language (IRR, 1.06; 95% CI, 1.02-1.10) were independent social factors associated with being passed over. The odds of a patient receiving care ahead of others were lower for ED visits by Medicare insured (odds ratio [OR], 0.92; 95% CI, 0.88-0.96), Medicaid insured (OR, 0.81; 95% CI, 0.77-0.85), Black non-Hispanic (OR, 0.94; 95% CI, 0.91-0.97), and Hispanic or Latino ethnicity (OR, 0.87; 95% CI, 0.83-0.91). Patients who were passed over by someone of the same triage severity level had higher odds of hallway bed placement (OR, 1.01; 95% CI, 1.00-1.02) and leaving before disposition (OR, 1.02; 95% CI, 1.01-1.04).Conclusions and RelevanceIn this cross-sectional study of ED patients in triage, there were consistent disparities among marginalized populations being more likely to experience a UQJ, hallway placement, and leaving without receiving treatment despite being assigned the same triage acuity as others. EDs should seek to standardize triage processes to mitigate conscious and unconscious biases that may be associated with timely access to emergency care.

Social determinants of health and emergency department visits among older adults with multimorbidity: insight from 2010 to 2018 National Health Interview Survey

“…The frequent complaints leading older people to visit EDs are shortness of breath, chest pain, and lower extremity pain/injury, and in approximately 75% of ED visits, older adults were triaged as urgent/emergent [ 13 ]. However, disparities in ED care access and triage processes exist based on race/ethnicity and health insurance status [ 19 ]. There is a need to identify and address disparities in emergency healthcare access in older people, which may produce disproportionated health outcomes [ 19 ].…”

“…However, disparities in ED care access and triage processes exist based on race/ethnicity and health insurance status [ 19 ]. There is a need to identify and address disparities in emergency healthcare access in older people, which may produce disproportionated health outcomes [ 19 ]. Therefore, this study aims to describe the association between SDoH and ED visits among older adults with multimorbidity.…”

Identifying Patient Subpopulations with Significant Race-Sex Differences in Emergency Department Disposition Decisions

“…Those who display potential acute coronary syndrome received different care depending on their sex 13 or if they were Caucasian or African American 14,15 . In addition, disparities have been shown to impact triage score assignment 16,17,18,19 as well as rooming prioritization 20,21 , with African-American and Hispanic patients receiving less acute scores and being less likely to be prioritized for rooming.…”