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Emergency department crowding negatively influences outcomes for adults presenting for chronic obstructive pulmonary disease

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Abstract

Objectives

Emergency department (ED) crowding leads to poor outcomes. Patients with respiratory conditions like chronic obstructive pulmonary disease (COPD) are especially vulnerable to crowding-related delays in care. We aimed to assess the associations of ED crowding metrics with outcomes for patients presenting with COPD.

Methods

We conducted a population-based cohort study of adult patients presenting with a diagnosis of COPD to 18 high-volume EDs between 2014 and 2019 in Alberta, Canada. Administrative databases provided date and time data on key stages of the presentation including physician initial assessment and disposition decision. Crowding metrics were calculated using facility-specific median physician initial assessment and length of stay. Patient presentations were grouped by acuity and mixed-effects regression models were fit to adjust for the clustering at the facility level.

Results

There were 49,085 presentations for COPD made by 25,734 patients (median age = 73 years). A 1-h increase in the physician initial assessment metric was associated with an increase in physician initial assessment for COPD patients by 23, 53, and 59 min for the high, moderate, and low acuity groups, respectively, adjusted for other predictors. For the low acuity group, this metric was associated with an increased length of stay of 73 min for admitted individuals. Similarly, an increase in the length of stay metric was also associated with an increased likelihood of being admitted for all acuity groups.

Conclusions

For patients with COPD, ED crowding results in delays in assessment increased length of stay, and increased proportion of patients admitted. These results suggest that ED crowding mitigation efforts to provide timely care for patients with COPD are urgently needed.

Trial registration

N/A.

Résumé

Objectifs

L'encombrement des services d'urgence entraîne de mauvais résultats. Les patients souffrant de maladies respiratoires telles que la maladie pulmonaire obstructive chronique (MPOC) sont particulièrement vulnérables aux retards de soins liés à l'encombrement. Notre avons cherché à évaluer les associations entre les paramètres d'encombrement des services d'urgence et les résultats pour les patients présentant une MPOC.

Méthodes

Nous avons mené une étude de cohorte basée sur la population de patients adultes se présentant avec un diagnostic de MPOC dans dix-huit services d'urgence à haut volume entre 2014 et 2019 en Alberta, au Canada. Les bases de données administratives ont fourni des données sur la date et l'heure des principales étapes de la présentation, y compris l'évaluation initiale par le médecin et la décision de sortie. Les mesures d'encombrement ont été calculées à partir de l'évaluation initiale médiane du médecin et de la durée du séjour propres à l'établissement. Les présentations des patients ont été regroupées par gravité et des modèles de régression à effets mixtes ont été ajustés pour tenir compte du regroupement au niveau de l'établissement.

Résultats

Il y a eu 49 085 présentations pour la MPOC effectuées par 25 734 patients (âge médian = 73 ans). Une augmentation d'une heure de l'évaluation initiale par le médecin était associée à une augmentation de l'évaluation initiale par le médecin pour les patients atteints de MPOC de 23, 53 et 59 min pour les groupes de gravité élevée, modérée et faible, respectivement, après ajustement pour d'autres facteurs prédictifs. Pour le groupe de faible gravité, ce paramètre était associé à une augmentation de la durée de séjour de 73 min pour les personnes admises. De même, une augmentation de la durée du séjour était également associée à une probabilité accrue d'admission pour tous les groupes de gravité.

Conclusions

Pour les patients atteints de MPOC, l'encombrement des urgences entraîne des retards dans l'évaluation, une augmentation de la durée du séjour et une augmentation de la proportion de patients admis. Ces résultats suggèrent qu'il est urgent d'atténuer l'encombrement des urgences afin de fournir des soins en temps opportun aux patients atteints de MPOC.

Enregistrement de l'essai

N/A.

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Data availability

Data is the property of Alberta Health and the authors are not allowed to provide the data. Requests can be made for the same data from Alberta Health for researchers who meet the criteria for access to confidential data. Researchers are welcome to inquire for further information at Health.RESDATA@gov.ab.ca.

References

  1. Moskop JC, Sklar DP, Geiderman JM, Schears RM, Bookman KJ. Emergency department crowding, part 1-concept, causes, and moral consequences. Ann Emerg Med. 2009;53(5):605–11.

    Article  PubMed  Google Scholar 

  2. Pines JM, Hollander JE, Localio AR, Metlay JP. The association between emergency department crowding and hospital performance on antibiotic timing for pneumonia and percutaneous intervention for myocardial infarction. Acad Emerg Med. 2006;13(8):873–8.

    Article  PubMed  Google Scholar 

  3. Schull MJ, Vermeulen M, Slaughter G, Morrison L, Daly P. Emergency department crowding and thrombolysis delays in acute myocardial infarction. Ann Emerg Med. 2004;44(6):577–85.

    Article  PubMed  Google Scholar 

  4. Johnson KD, Winkelman C. The effect of emergency department crowding on patient outcomes: a literature review. Adv Emerg Nurs J. 2011;33(1):39–54.

    Article  PubMed  Google Scholar 

  5. Pines JM, Hilton JA, Weber EJ, Alkemade AJ, Al Shabanah H, Anderson PD, et al. International perspectives on emergency department crowding. Acad Emerg Med. 2011;18(12):1358–70.

    Article  PubMed  Google Scholar 

  6. Bernstein SL, Aronsky D, Duseja R, Epstein S, Handel D, Hwang U, et al. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med. 2009;16(1):1–10.

    Article  PubMed  Google Scholar 

  7. Fee C, Weber EJ, Maak CA, Bacchetti P. Effect of emergency department crowding on time to antibiotics in patients admitted with community-acquired pneumonia. Ann Emerg Med. 2007;50(5):501–9.e1.

    Article  PubMed  Google Scholar 

  8. Jang H, Ozkaynak M, Ayer T, Sills MR. Factors associated with first medication time for children treated in the emergency department for asthma. Pediatr Emerg Care. 2021;37(1):e42–7.

    Article  PubMed  Google Scholar 

  9. Sills MR, Fairclough D, Ranade D, Kahn MG. Emergency department crowding is associated with decreased quality of care for children with acute asthma. Ann Emerg Med. 2011;57(3):191–200.e7.

    Article  PubMed  Google Scholar 

  10. Crighton EJ, Ragetlie R, Luo J, To T, Gershon A. A spatial analysis of COPD prevalence, incidence, mortality and health service use in Ontario. Health Rep - Stat Canada. 2015;26(3):10–8.

    Google Scholar 

  11. Charbonneau V, Kwok E, Boyle L, Stiell IG. Impact of emergency department surge and end of shift on patient workup and treatment prior to referral to internal medicine: a health records review. Emerg Med J. 2018;35(5):309–15.

    PubMed  Google Scholar 

  12. Feinleib M, Rosenberg HM, Collins JG, Delozier JE, Pokras R, Chevarley FM. Trends in COPD morbidity and mortality in the United States. Am Rev Respir Dis. 1989;140(3 Pt 2):S9–18.

    Article  CAS  PubMed  Google Scholar 

  13. Wedzicha JA, Donaldson GC. Exacerbations of chronic obstructive pulmonary disease. Respir Care. 2003;48(12):1204–13.

    PubMed  Google Scholar 

  14. Hwang U, McCarthy ML, Aronsky D, Asplin B, Crane PW, Craven CK, et al. Measures of crowding in the emergency department: a systematic review. Acad Emerg Med. 2011;18(5):527–38.

    Article  PubMed  Google Scholar 

  15. Canadian Institute for Health Information. ICD-10-CA (International Statistical Classification of Diseases and Related Health Problems), 10th Revision. Ottawa, ON: Canadian Institute for Health Information; 2020.

  16. Gravel J, Manzano S, Arsenault M. Validity of the Canadian paediatric triage and acuity scale in a tertiary care hospital. Can J Emerg Med. 2009;11(1):23–8.

    Article  Google Scholar 

  17. Bullard MJ, Unger B, Spence J, Grafstein E. Revisions to the Canadian Emergency Department Triage and Acuity Scale (CTAS) adult guidelines. Can J Emerg Med. 2008;10(2):136–51.

    Article  Google Scholar 

  18. Wilkins R, Peters PA. PCCF + Version 5K* User's Guide. Automated geographic coding based on the Statistics Canada Postal Code Conversion Files, Including Postal Codes through May 2011. Ottawa, ON: Statistics Canada; 2012.

  19. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83.

    Article  CAS  PubMed  Google Scholar 

  20. Medicore (Firm). ICD-9-CM: International classification of diseases, 9th revision, clinical modification. Salt Lake City, Utah: Medicore; 1996.

  21. Canadian Institute for Health Information. eNACRS Reports: Emergency Department Wait Time Indicators. Ottawa, Ontario: Canadian Institute for Health Information; 2012.

  22. SAS Institute Inc. SAS/ACCESS® 9.4 Interface to ADABAS: Reference. Cary, NC: SAS Institute Inc.; 2013.

  23. R Core Team. R: A language and environment for statistical computing. 4.0.4 ed. Vienna, Austria: R Foundation for Statistical Computing; 2021.

  24. Sagaidak S, Rowe BH, Ospina MB, Rosychuk RJ. Emergency department crowding negatively influences outcomes for children presenting with asthma: a population-based retrospective cohort study. Pediatr Res. 2021;89(3):679–85.

    Article  PubMed  Google Scholar 

  25. Rasouli HR, Esfahani AA, Nobakht M, Eskandari M, Mahmoodi S, Goodarzi H, et al. Outcomes of crowding in emergency departments; a systematic review. Arch Acad Emerg Med. 2019;7(1): e52.

    PubMed  PubMed Central  Google Scholar 

  26. Ouyang H, Wang J, Sun Z, Lang E. The impact of emergency department crowding on admission decisions and patient outcomes. Am J Emerg Med. 2022;51:163–8.

    Article  PubMed  Google Scholar 

  27. O’Donnell DE, Aaron S, Bourbeau J, Hernandez P, Marciniuk DD, Balter M, et al. Canadian thoracic society recommendations for management of chronic obstructive pulmonary disease - 2007 update. Can Respir J. 2007;14:5b–32b.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Affleck A, Parks P, Drummond A, Rowe BH, Ovens HJ. Emergency department overcrowding and access block. Can J Emerg Med. 2013;15(6):359–84.

    Article  Google Scholar 

  29. Holroyd BR, Bullard MJ, Latoszek K, Gordon D, Allen S, Tam S, et al. Impact of a triage liaison physician on emergency department overcrowding and throughput: a randomized controlled trial. Acad Emerg Med. 2007;14(8):702–8.

    Article  PubMed  Google Scholar 

  30. Rowe BH, Guo X, Villa-Roel C, Schull M, Holroyd B, Bullard M, et al. The role of triage liaison physicians on mitigating overcrowding in emergency departments: a systematic review. Acad Emerg Med. 2011;18(2):111–20.

    Article  PubMed  Google Scholar 

  31. Bullard MJ, Villa-Roel C, Guo X, Holroyd BR, Innes G, Schull MJ, et al. The role of a rapid assessment zone/pod on reducing overcrowding in emergency departments: a systematic review. Emerg Med J. 2012;29(5):372–8.

    Article  PubMed  Google Scholar 

  32. Oredsson S, Jonsson H, Rognes J, Lind L, Göransson KE, Ehrenberg A, et al. A systematic review of triage-related interventions to improve patient flow in emergency departments. Scand J Trauma Resusc Emerg Med. 2011;19:43.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Jones S, Moulton C, Swift S, Molyneux P, Black S, Mason N, et al. Association between delays to patient admission from the emergency department and all-cause 30-day mortality. Emerg Med J. 2022;39(3):168.

    Article  PubMed  Google Scholar 

  34. Wessman T, Ärnlöv J, Carlsson AC, Ekelund U, Wändell P, Melander O, et al. The association between length of stay in the emergency department and short-term mortality. Intern Emerg Med. 2022;17(1):233–40.

    Article  PubMed  Google Scholar 

  35. De Freitas L, Goodacre S, O’Hara R, Thokala P, Hariharan S. Interventions to improve patient flow in emergency departments: an umbrella review. Emerg Med J. 2018;35(10):626–37.

    Article  PubMed  Google Scholar 

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Acknowledgements

The authors would like to thank Meng Lin of the Alberta SPOR data platform and AHS Research Data Services for providing health datasets. The authors would also like to thank Larry Laliberte at the University of Alberta for providing the Statistics Canada data.

Funding

Dr. Rowe’s research is supported by a Scientific Director’s Grant (SOP 168483) from the Canadian institutes of Health Research (CIHR) through the Government of Canada (Ottawa, ON). These funding organizations were not involved in any aspect of the conduct, analysis, or manuscript preparation of this research; CIHR takes no responsibility for the results reported in this manuscript.

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Authors and Affiliations

  1. Department of Pediatrics, Edmonton Clinic Health Academy, University of Alberta, Edmonton, AB, Canada

    Silvia S. Ortiz, Yifu Huang & Rhonda J. Rosychuk

  2. Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada

    Brian H. Rowe & Bo Zheng

  3. School of Public Health, University of Alberta, Edmonton, AB, Canada

    Brian H. Rowe

Authors
  1. Silvia S. Ortiz
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Contributions

SSO performed the statistical analysis and assisted with modeling analysis, interpreted results, and drafted and reviewed the manuscript. YH assisted with statistical and performed the modeling analyses, and reviewed the manuscript. BHR conceptualized and designed the study, interpreted results, and reviewed and revised the manuscript. BZ interpreted results, and reviewed and revised the manuscript. RJR conceptualized and designed the study, coordinated data extraction, and provided project oversight by directing statistical analyses, interpreting results, and reviewing and revising the manuscript. RJR is the guarantor for this manuscript and accepts responsibility for all aspects.

Corresponding author

Correspondence to Rhonda J. Rosychuk.

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The authors have no conflicts of interest to disclose.

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Ortiz, S.S., Huang, Y., Rowe, B.H. et al. Emergency department crowding negatively influences outcomes for adults presenting for chronic obstructive pulmonary disease. Can J Emerg Med 25, 411–420 (2023). https://doi.org/10.1007/s43678-023-00502-5

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  • DOI: https://doi.org/10.1007/s43678-023-00502-5

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