Emergency department crowding is associated with 28-day mortality in community-acquired pneumonia patients

doi:10.1016/j.jinf.2011.12.007

Journal of Infection

Volume 64, Issue 3, March 2012, Pages 268-275

https://doi.org/10.1016/j.jinf.2011.12.007 Get rights and content

Summary

Object

Although emergency department (ED) crowding has been shown to be associated with delayed antibiotics treatment in community-acquired pneumonia (CAP) patients, association between ED crowding with mortality has not been investigated. We hypothesized emergency department crowding is associated with 28-day mortality in CAP patients.

Methods

A retrospective observational study using prospective database was performed on CAP patients who visited a single, urban, tertiary care hospital ED between April 1, 2008 and September 30, 2009. Main outcomes were 28-day mortality and timeliness of antibiotic therapy (within 2, 4, 6, and 8 h of arrival). ED crowding was measured by Emergency Department Occupancy (EDO) rate. A multivariate logistic regression was performed to determine the association of 28-day mortality with EDO rate after adjusting for factors such as time-to-first-antibiotic-dose (TFAD), pneumonia severity index and laboratory markers.

Results

477 cases were enrolled during the study period. 28-day mortality rate was 4.8%. EDO rate ranged from 37.2% to 162.8%, and median was 97.7% (IQR: 80.2%–116.3%). When categorized into tertiles by EDO rate, high crowding condition (EDO rate >109.3%) was significantly associated with a higher 28-day mortality (adjusted OR = 9.48, 95% CI 1.53–58.90). However, TFAD was not associated with 28-day mortality. ED crowding was not associated with delay of TFAD at various time intervals (2, 4, 6, and 8 h).

Conclusions

ED crowding measured by EDO rate was associated with higher 28-day mortality in CAP patients after adjusting TFAD, pneumonia severity index (PSI), and laboratory markers, although there was no association between ED crowding and TFAD.

Introduction

Because emergency department (ED) crowding has been reported to cause delays in diagnosis and treatment, decrease of quality-of-care, and poor outcomes,1, 2 ED crowding has been highlighted as a global health problem. Many crowding scales have been developed such as the National Emergency Department Overcrowding Scale (NEDOCS),³ the Emergency Department Work Index (EDWIN),⁴ the Real-time Emergency Analysis of Demand Indicator (READI),⁵ the Emergency Department Crowding Scale (EDCS)⁶ and the Work Score (WS).⁷ However, there is no agreement as to which definition of ED crowding should be used. Moreover, these scales have limitations to quantifying real-time overcrowding because many EDs are not equipped with electronic tracking systems to calculate these scales in real-time.8, 9 Recently, one simple measure, Emergency Department Occupancy (EDO) rate was conceptualized.¹⁰ Using the concept of ‘occupancy’ alone, not exact EDO, two Australian studies showed an association between increased mortality and ED crowding.11, 12 Considering its simplicity, calculating the EDO rate and the real-time quantification of ED crowding by this scale seems to be easy for many EDs.

For community-acquired pneumonia (CAP) patients, recent studies have shown that ED crowding is associated with a delayed time to first antibiotic dose (TFAD).13, 14, 15 However, it is uncertain whether ED crowding is associated with poor outcomes in CAP patients. Thus, study revealing the impact of ED crowding on the mortality in CAP patients is needed.

The purpose of this study was to determine whether there is an association between ED crowding as measured by the EDO rate and mortality in patients who present at the ED with CAP. We hypothesized that ED crowding using the EDO rate is associated with increased mortality in CAP patients.

Section snippets

Study design and setting

This study was approved by the Institutional Review Board (IRB) of the study hospital, and a waiver for consent was given. We performed a retrospective observational study. This study was part of a prospective quality improvement study to implement Pneumonia Severity Index (PSI) in the admission protocol.¹⁶ IRB number is B-1103/123–104.

The study was conducted at a 950-bed urban academic tertiary care hospital with an annual ED census of 67,000. The ED is staffed by board-certified emergency

Baseline characteristics

During the study period, 597 patients met the initial eligibility criteria. Among these patients, we then excluded patients as follows: 1) 3 patients less than 18 years of age, 2) 116 patients transferred from another facility and 3) 1 patient who left against medical advice or discontinued care on the day of or the day after arrival. Finally, 477 patients were enrolled in our study.

The median age was 67 years (IQR: 51–76), and 266 patients (56.2%) were male. Twenty-three patients (4.8%) were

Discussion

We demonstrated that high crowding group was associated with significantly higher mortality than the low crowding group. Surprisingly, there was no significant association between ED crowding and the time to first antibiotic dose delivery.

After it was reported that timely antibiotics administration was associated with the improvement of CAP patient outcomes,18, 19, 20 TFAD has been regarded as a quality-of-care measure. The Hospital Quality Alliance (HQA), the Joint Commission (TJC), the

Limitations

The results of this study must be interpreted after considering some limitations. First, this result represents a single urban academic ED, and the results of this study cannot be generalized to other setting. Second, there were some missing mortality data even after making follow up phone call. The number, however, is small, so we do not think these missing data influenced our results significantly. Third, we did not collect data about the time to use of critical care such as the use of

Conclusion

CAP patients in the high crowding group showed significantly higher 28-day mortality rates than those in the low crowding group. However, there was no association between ED crowding and TFAD in this study.

Financial support

None declared.

Conflict of interest

None declared.

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Emergency department crowding is associated with 28-day mortality in community-acquired pneumonia patients

Summary

Object

Methods

Results

Conclusions

Introduction

Section snippets

Study design and setting

Baseline characteristics

Discussion

Limitations

Conclusion

Financial support

Conflict of interest

Ann Emerg Med

Emerg Med Clin North Am

Ann Emerg Med

Am J Emerg Med

Am J Med

Am J Emerg Med

Ann Emerg Med

Ann Emerg Med

Emergency department overload: a growing crisis. The results of the American Hospital Association survey of emergency department (ED) and hospital capacity

Estimating the degree of emergency department overcrowding in academic medical centers: results of the National ED Overcrowding Study (NEDOCS)

Acad Emerg Med

Development and validation of a new index to measure emergency department crowding

Acad Emerg Med

When the safety net is unsafe: real-time assessment of the overcrowded emergency department

Acad Emerg Med

Comparison of the National emergency department overcrowding scale and the emergency department work index for quantifying emergency department crowding

Acad Emerg Med

Development of an emergency department work score to predic ambulance diversion

Acad Emerg Med

Use of computerized clinical support systems in medical settings: United States, 2001–2003

Adv Data

The emergency department occupancy rate: a simple measure of emergency department crowding?

Ann Emerg Med