Abstract
BackgroundEmergency Department (ED) crowding is a pervasive problem, yet there have been few comparisons of the extent of, and contributors to, crowding among different types of EDs. The study quantifies and compares crowding metrics for 16 high volume regional, urban and academic EDs in one Canadian province.MethodsThe National Ambulatory Care Reporting System (NACRS) provided ED presentations by adults to 16 high volume Alberta EDs during April 2010 to March 2015 for this retrospective cohort study. Time to physician initial assessment (PIA), length of stay (LOS) for discharges and admissions were grouped by start hour of presentation and facility. Multiple crowding metrics were created by taking the means, medians (PIA-M, LOS-M), and 90th percentiles of the hourly, ED-specific values. Similarly, proportion left against medical advice (LAMA) and proportion left without being seen (LWBS) were day and ED aggregated. Calculated based on the start of the presentation and the facility and for PIA and LOS. The mean, median, and 90th percentiles for the date and time ED-specific metrics for PIA and LOS were obtained. Summary statistics were used to describe crowding metrics.ResultsThere were 3,925,457 presentations by 1,420,679 adults. The number of presentations was similar for each sex and the mean age was 46 years. Generally, the three categories of EDs had similar characteristics; however, urban and academic/teaching EDs had more urgent triage scores and a higher percentage of admissions than regional EDs. The median of the PIA-M metric was 1 h23m across all EDs. For discharges, the median of the LOS-M metric was 3h21m whereas the median of the LOS-M metric for admissions was 10h08m. Generally, regional EDs had shorter times than urban and academic/teaching EDs. The median daily LWBS was 3.4% and the median daily LAMA was about 1%.ConclusionsEmergency presentations have increased over time, and crowding metrics vary considerably among EDs and over the time of day. Academic/teaching EDs generally have higher crowding metrics than other EDs and urgent action is required to mitigate the well-known consequences of ED crowding.
Highlights
Emergency Department (ED) crowding is a pervasive problem, yet there have been few comparisons of the extent of, and contributors to, crowding among different types of EDs
The consequences of ED crowding can be serious as patients may not receive timesensitive interventions, may leave without being seen by a physician (LWBS) or against medical advice (LAMA), and if critically ill, may have longer lengths of stay in hospital or greater hospital mortality [8]
ED crowding is believed to be influenced by multiple factors and in Canadian hospitals, the most important factor leading to ED crowding is the lack of in-patient beds for those presenting to the ED who need to be admitted [3]
Summary
Emergency Department (ED) crowding is a pervasive problem, yet there have been few comparisons of the extent of, and contributors to, crowding among different types of EDs. The study quantifies and compares crowding metrics for 16 high volume regional, urban and academic EDs in one Canadian province. High-volume, tertiary care EDs in North America continue to face a crowding crisis and the quality of care can suffer during any peak periods of demand. The multiple influencing factors are related to aspects of patient flow and can be characterized by a conceptual model with input, throughput, and output [1]. Throughput, and output respectively refer to how patients arrive in the ED (e.g., ambulatory, via ambulance or referral), the processes of ED care, and their eventual disposition (e.g., LWBS/LAMA, discharge/admission, transfer, death). Multiple metrics have been defined to capture the input, throughput, and output aspects
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