Variations in Crowding and Ambulance Diversion in Nine Emergency Departments

Handel, Daniel A.; Pines, Jesse M.; Aronsky, Dominik; Genes, Nicholas; Ginde, Adit A.; Hackman, Jeffrey L.; Hilton, John; Hwang, Ula; Kamali, Michael; Powell, Elizabeth; Sattarian, M.; Fu, Rongwei

doi:10.1111/j.1553-2712.2011.01149.x

Cited by 17 publications

(13 citation statements)

References 22 publications

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“…It is known that hospitals have different thresholds to activate diversion. 49 It is precisely this variation, along with our findings, that allows us to conclude that system-level policies regulating ambulance diversion provides policy-makers, healthcare providers, and hospital administrations may help reduce diversion and its associated inequalities. Indeed, statewide and national efforts have been undertaken to implement no-diversion policies, although none yet in California.…”

Section: Discussionsupporting

confidence: 50%

California Hospitals Serving Large Minority Populations Were More Likely Than Others To Employ Ambulance Diversion

et al. 2012

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We evaluate whether hospitals serving a higher proportion of minorities experience disproportionate emergency department crowding, as proxied by ambulance diversion. In 202 hospitals across California, the median number of annual diversion hours was 374. After controlling for hospital characteristics, hospitals at the tenth percentile of fraction of minority visitors were on diversion only seventy-five hours per year, compared with hospitals at the ninetieth percentile, with 306 annual diversion hours. Emergency department crowding disproportionately affects minorities, and may contribute to health disparities in these communities. These findings suggest that establishing more uniform criteria regulating diversion may be one step toward decreasing disparities in access to emergency care.

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Section: Discussionsupporting

confidence: 50%

California Hospitals Serving Large Minority Populations Were More Likely Than Others To Employ Ambulance Diversion

et al. 2012

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“…The need for ambulance diversion data is mitigated by direct measures of patient transit time and bed occupancy. Diversion can exist independently of other ED crowding measures, 37 and thus may partly depend on factors such as the emergency medical system. Fourth, as our focus was on population outcomes, we did not focus on high-risk conditions (eg, pneumonia).…”

Section: Discussionmentioning

confidence: 99%

Emergency Department Crowding Predicts Admission Length-of-Stay But Not Mortality in a Large Health System

et al. 2014

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Background Emergency department (ED) crowding has been identified as a major threat to public health. Objectives We assessed patient transit times and ED system crowding measures based on their associations with outcomes. Research Design Retrospective cohort study. Subjects We accessed electronic health record data on 136,740 adults with a visit to any of 13 health system EDs from January 2008 to December 2010. Measures Patient transit times (waiting, evaluation and treatment, boarding) and ED system crowding [nonindex patient length-of-stay (LOS) and boarding, bed occupancy] were determined. Outcomes included individual inpatient mortality and admission LOS. Covariates included demographic characteristics, past comorbidities, severity of illness, arrival time, and admission diagnoses. Results No patient transit time or ED system crowding measure predicted increased mortality after control for patient characteristics. Index patient boarding time and lower bed occupancy were associated with admission LOS (based on nonoverlapping 95% CI vs. the median value). As boarding time increased from none to 14 hours, admission LOS increased an additional 6 hours. As mean occupancy decreased below the median (80% occupancy), admission LOS decreased as much as 9 hours. Conclusions Measures indicating crowded ED conditions were not predictive of mortality after case-mix adjustment. The first half-day of boarding added to admission LOS rather than substituted for it. Our findings support the use of boarding time as a measure of ED crowding based on robust prediction of admission LOS. Interpretation of measures based on other patient ED transit times may be limited to the timeliness of care.

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“…51 Admission to an ED when in the throes of an ACS is a stressful experience, and when that ED is overcrowded, it is exceedingly stressful. 21,52 ED crowding varies greatly through the course of a single day in most hospitals throughout the US, 17,19,53 and is associated with greater in-hospital 17,20 30-day, and 1-year post-ACS mortality. ACS patients treated during times when the ED is most crowded are 3 to 5 times more likely to experience subsequent in-hospital MI than those treated during less crowded times and are at significantly greater subsequent MI/mortality risk.…”

Section: Depression and Arrhythmogenesismentioning

confidence: 99%

The ‘Perfect Storm’ and Acute Coronary Syndrome Onset: Do Psychosocial Factors Play a Role?

Burg¹,

Edmondson²,

Shimbo³

et al. 2013

Progress in Cardiovascular Diseases

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The revolution in cardiac care over the past two decades, characterized by emergent revascularization, drug eluting stents, anti-platelet medications, and advanced imaging has had little impact on overall ACS recurrence, or ACS prevention. The "Perfect Storm" refers to a confluence of events and processes, including atherosclerotic plaque, coronary flow dynamics, hemostatic and fibrinolytic function, metabolic and inflammatory conditions, neurohormonal dysregulation, and environmental events that give rise to, and result in an ACS event. In this article we illustrate the limits of the traditional main effect research model, giving a brief description of the current state of knowledge regarding the development of atherosclerotic plaque and the rupturing of these plaques that defines an ACS event. We then apply the Perfect Storm conceptualization to describe a program of research concerning a psychosocial vulnerability factor that contributes to increased risk of recurrent ACS and early mortality, and that has defied our efforts to identify underlying pathophysiology and successfully mount efforts to fully mitigate this risk.There is a "Perfect Storm" coming. Although this metaphor has been used to warn us about the ongoing U.S. fiscal crisis and about impending weather events, it is also a potentially useful metaphor when applied to the occurrence of an acute coronary syndrome (ACS). 1,2 The "Perfect Storm" as a conceptual model applied to ACS proposes to us that ACS events are not caused by the presence of a single, or even a number of specific coronary heart disease (CHD) risk factors, but rather results from an unfortunate confluence involving any of several stable underlying CHD vulnerability factors and the co-occurrence of any of several situational or environmental events that acutely activate critical physiological processes, thereby contributing overall to a period of increased risk. 3 Thus the "Perfect" ACS storm is defined as the joint presence of many co-occurring pathophysiologic processes that lead to a clinical event. This Perfect Storm will happen for more than 1 million American adults each year. Many of these individuals will join the more than 17 million living American adults who have survived an ACS but continue to suffer from the cardiovascular damage remaining after the ACS event. 4 Understanding how the Perfect Storm model aids in the investigation of this large public health problem is an exciting © 2013 Elsevier Inc. All rights reserved.Correspondence should be addressed to: Karina W. Davidson, Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical Center, PH9, Room 9-319, 622 W. 168th Street, New York, NY 10032, kd2124@columbia.edu. Conflict of interest statement: None to reportPublisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of th...

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Variations in Crowding and Ambulance Diversion in Nine Emergency Departments

Cited by 17 publications

References 22 publications

California Hospitals Serving Large Minority Populations Were More Likely Than Others To Employ Ambulance Diversion

California Hospitals Serving Large Minority Populations Were More Likely Than Others To Employ Ambulance Diversion

Emergency Department Crowding Predicts Admission Length-of-Stay But Not Mortality in a Large Health System

The ‘Perfect Storm’ and Acute Coronary Syndrome Onset: Do Psychosocial Factors Play a Role?

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