Abstract 16216: Emergency Department Crowding Does Not Predict Door-In-Door-Out Time for Acute Myocardial Infarction Patients Transferred for Acute Coronary Intervention

Abstract

Introduction: Emergency department (ED) crowding and prolonged length of stay (LOS) are associated with lower quality care. Patients with acute myocardial infarction (AMI) should be transferred to percutaneous coronary intervention capable facilities within 45 minutes of arrival. Hypothesis: Increased ED crowding, as measured by ED LOS, is correlated with longer AMI door-in-door-out (DIDO) times at transferring EDs. Methods: We analyzed the Centers for Medicare and Medicaid Services (CMS) quality data. The outcome, DIDO, was CMS measure OP-3b, ED Median Time to Transfer a Patient with AMI for Acute Coronary Intervention . OP-3b data included hospitals with ≥10 AMI cases annually. To measure ED crowding, we used the CMS ED timeliness measures: discharged LOS, admitted LOS, boarding, and waiting time to be seen by a provider. Our primary measure of interest was ED-1: Median ED LOS for Admitted Patients . We analyzed bivariate associations between DIDO and ED timeliness measures. We used linear regression to evaluate the contribution of hospital characteristics from the American Hospital Association survey (academic, trauma, rural, ED volume) to DIDO. Results: Data were available for 405 out of 4,129 hospitals for the CMS DIDO measure (934 had <10 cases). These facilities were primarily non-academic (99%), non-trauma centers (65%), in metro locations (68.6%). Median DIDO was 54 minutes (IQR 42, 68). Increased DIDO time was associated with longer admitted LOS, and boarding times, but not waiting time or discharged LOS. Mean ED admitted LOS was different between hospitals with average DIDO <45 versus those ≥45 minutes (259 vs. 283 minutes; p=0.008). After adjusting for hospital characteristics, longer ED admitted LOS at referring facilities [coefficient, 0.078 (95% CI 0.042, 0.113); p<0.001] was associated with DIDO. A 13 minute increase in ED admitted LOS was associated with a 1 minute increase in DIDO. Among hospital characteristics only rural status was associated with longer DIDO. Conclusions: Among AMI patients presenting to U.S. EDs, we found that ED crowding has a small but operationally insignificant effect on AMI DIDO times. EDs have found ways to facilitate timely transfer of AMI patients despite crowding.