Comparison of emergency physicians and internists regarding core measures of care for admitted emergency department boarders with pneumonia

Abstract

The inability to admit emergency patients to inpatient beds is the single most important causes of emergency department (ED) crowding. ED crowding increases frustration, risks of medical errors and poor outcomes. Delays to admission are associated with increased inpatient length of stay, cost and mortality. Nevertheless, no patient harm was found in selected ED-boarded admitted patients who were relocated to an inpatient hallway and were cared by internists. To compare quality of cares and short-term outcomes in emergency department boarders admitted for pneumonia cared by the emergency physician (EP) and the internist. This is a retrospective, cross-sectional study in a tertiary referral hospital. We board admitted patients in the ED observation units when there is no inpatient bed and transfer is not available. Besides EPs, internists cared parts of boarders from February 1st to August 31st in 2010. We retrieved admitted pneumonia patients, aged 18 years or older, who boarded in the ED longer than 6 hours. We excluded patients with severe pneumonia admitted to intensive care units, human immunodeficiency virus infection, leukemia or lymphoma diagnosed within 3 months, bronchiectasis, malnutrition, or who receiving systemic chemotherapy, immunosuppression therapy, comfort care, based on established instrument of quality measures. Enrolled patients were stratified into EP or internist caring groups. We collected their demographics, co-morbidities, symptoms, vital signs, and laboratory results. Severity of the pneumonia was assessed by the pneumonia severity index and the CURB-65 score. Quality of care was assessed by established core measures. We analyzed dichotomous variables with the Fisher's exact test. For continuous variables, we used the Student's t test for paramedic variables, and the Mann-Whitney U test for non-parametric variables. Difference was considered as significant at a p level of 0.05. Ninety-four patients were enrolled: 59 cared by EPs and 35 by internists. Between EP and internist caring groups, there was no significant difference in age, sex, and pneumonia severity. In the core measures of quality, there was no significant difference in oxygenation assessment, first antibiotics within 6 hours of presentation, blood culture before antibiotic administration, and proper antibiotics within 24 hours. Internists provided more smoking counseling (31.4% vs 10.2%; p = 0.013). Both EP and internist did little vaccination counseling. In short-term outcomes, no difference was found in length of stay, late ICU admission, unscheduled ED returns, and 30-day readmission or mortality rates. For ED boarders admitted for pneumonia, EPs provided less smoking counseling than internists. However, there was no significant difference in other core measures of quality and short-term outcomes.