Skip to main content Accessibility help
×
Home

Better performance on length-of-stay benchmarks associated with reduced risk following emergency department discharge: an observational cohort study

  • Michael Schull (a1) (a2) (a3) (a4), Marian Vermeulen, Astrid Guttmann (a1) (a5) (a3) (a6) and Therese Stukel (a1) (a3)

Abstract

Introduction

Emergency department (ED) crowding is associated with adverse outcomes. Several jurisdictions have established benchmarks and targets for length-of-stay (LOS) to reduce crowding. An evaluation has been conducted on whether performance on Ontario’s ED LOS benchmarks is associated with reduced risk of death or hospitalization.

Methods

A retrospective cohort study of discharged ED patients was conducted using population-based administrative data from Ontario (April 2008 to February 2012). For each ED visit, the proportion of patients seen during the same shift that met ED LOS benchmarks was determined. Performance was categorized as <80%, 80% to <90%, 90% to <95%, and 95%–100% of same-shift ED patients meeting the benchmark. Logistic regression models analysed the association between performance on ED LOS benchmarks and 7-day death or hospitalization, controlled for patient and ED characteristics and stratified by patient acuity.

Results

From 122 EDs, 2,295,256 high-acuity and 1,626,629 low-acuity visits resulting in discharge were included. Deaths and hospitalizations within 7 days totalled 1,429 (0.062%) and 49,771 (2.2%) among high-acuity, and 220 (0.014%) and 9,005 (0.55%) among low-acuity patients, respectively. Adverse outcomes generally increased among patients seen during shifts when a lower proportion of ED patients met ED LOS benchmarks. The adjusted odds ratios (and 95% confidence intervals) among high- and low-acuity patients seen on shifts when <80% met ED benchmarks (compared with ≥95%) were, respectively, 1.32 (1.05–1.67) and 1.84 (1.21–2.81) for death, and 1.13 (1.08–1.17) and 1.40 (1.31–1.49) for hospitalization.

Conclusions

Better performance on Ontario’s ED LOS benchmarks for each shift is associated with a 10%–45% relative reduction in the odds of death or admission 7 days after ED discharge.

Contexte

L’encombrement des services d’urgence (SU) est associé à des résultats défavorables. Des valeurs de référence et des cibles relatives à la durée de séjour (DS) ont été établies dans plusieurs provinces ou pays afin de réduire l’encombrement. L’étude visait donc à évaluer si le rendement fondé sur des valeurs de référence concernant la DS dans les SU en Ontario était associé à une réduction du risque de mortalité ou d’hospitalisation.

Méthode

Une étude rétrospective de cohortes composées de patients ayant quitté les SU a été menée à l’aide de données administratives fondées sur la population et recueillies en Ontario (avril 2008 à février 2012). Les auteurs ont déterminé, pour chacune des consultations au SU, la proportion de patients vus au cours d’une même période de travail qui respectait les valeurs de référence établies pour la DS dans les SU. Le degré de performance a été défini comme la proportion de patients vus au cours d’un même période de travail au SU ayant respecté les valeurs de référence, à hauteur de <80%, de 80 à <90%, de 90 à <95% et de 95 à 100%. Des modèles de régression logistique ont permis d’analyser l’association entre le rendement fondé sur des valeurs de référence concernant la DS dans les SU et la mortalité ou l’hospitalisation au bout de 7 jours, de garder fixes les caractéristiques des patients et des SU et de diviser les patients selon leur état de gravité.

Résultats

L’étude comptait 2 295 256 consultations pour des états graves et 1 626 629 consultations pour des états non graves, données dans 122 SU, qui se sont soldées par le renvoi des patients. Le nombre de décès et d’hospitalisations au bout de 7 jours atteignait respectivement 1429 (0,062%) et 49 771 (2,2%) parmi les cas graves, et 220 (0,014%) et 9005 (0,55%) parmi les cas peu graves. Une augmentation générale des résultats défavorables a été notée au cours des périodes de travail durant lesquelles une faible proportion de patients vus au SU respectait les valeurs de référence établies pour la DS dans les SU. Les risques relatifs approchés, rajustés (intervalle de confiance à 95%) chez les patients qui étaient dans un état grave et chez ceux qui ne l’étaient pas, vus au cours de périodes de travail durant lesquelles <80% des valeurs de référence fixées dans les SU (comparativement à un taux de ≥95%) étaient respectées se sont établis respectivement à 1,32 (1,05–1,67) et à 1,84 (1,21–2,81) en ce qui concerne la mortalité et à 1,13 (1,08–1,17) et à 1,40 (1,31–1,49) en ce qui concerne l’hospitalisation.

Conclusion

Une augmentation du rendement fondé sur des valeurs de référence concernant la DS dans les SU en Ontario pour chaque période de travail est associée à une réduction relative du risque de mortalité ou d’hospitalisation de l’ordre de 10 à 45% au bout de 7 jours après le congé du SU.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Better performance on length-of-stay benchmarks associated with reduced risk following emergency department discharge: an observational cohort study
      Available formats
      ×

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Better performance on length-of-stay benchmarks associated with reduced risk following emergency department discharge: an observational cohort study
      Available formats
      ×

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Better performance on length-of-stay benchmarks associated with reduced risk following emergency department discharge: an observational cohort study
      Available formats
      ×

Copyright

Corresponding author

Correspondence to: Marian Vermeulen, Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, ON M4N 3M5; marian.vermeulen@ices.on.ca

References

Hide All
1. Pines, JM, Localio, AR, Hollander, JE, et al. The impact of emergency department crowding measures on time to antibiotics for patients with community-acquired pneumonia. Ann Emerg Med 2007;50(5):510-516. doi:10.1016/j.annemergmed.2007.07.021.
2. Schull, MJ, Vermeulen, M, Slaughter, G, et al. Emergency department crowding and thrombolysis delays in acute myocardial infarction. Ann Emerg Med 2004;44(6):577-585. doi:10.1016/j.annemergmed.2004.05.004.
3. Hwang, U, Richardson, LD, Sonuyi, TO, Morrison, RS. The effect of emergency department crowding on the management of pain in older adults with hip fracture. J Am Geriatr Soc 2006;54(2):270-275. doi:10.1111/j.1532-5415.2005.00587.x.
4. Pines, JM, Hollander, JE. Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med 2008;51(1):1-5. doi:10.1016/j.annemergmed.2007.07.008.
5. Guttmann, A, Schull, MJ, Vermeulen, MJ, Stukel, TA. Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ 2011;342(jun01 1):d2983-d2983. doi:10.1136/bmj.d2983.
6. Richardson, DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust 2006;184(5):213-216.
7. Sprivulis, PC, Da Silva, JA, Jacobs, IG, et al. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust 2006;184(5):208-212.
8. Miro, O, Antonio, M, Jimenez, S. Decreased health care quality associated with emergency department overcrowding. Eur J Emerg Med 1999;6:105-107.
9. Chalfin, DB, Trzeciak, S, Likourezos, A, et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med 2007;35(6):1477-1483. doi:10.1097/01.CCM.0000266585.74905.5 A.
10. Pines, JM, Hilton, JA, Weber, EJ, et al. International perspectives on emergency department crowding. Acad Emerg Med 2011;18(12):1358-1370. doi:10.1111/j.1553-2712.2011.01235.x.
11. Medicare. Emergency department throughput measures . 2013. Available at: http://www.medicare.gov/hospitalcompare/(X(1)S(efcfimz1hv0glomky5evj3hz))/data/emergency-wait-times.aspx?AspxAutoDetectCookieSupport=1 (accessed July 3, 2013).
12. Affleck, A, Parks, P, Drummond, A, et al. Emergency department overcrowding and access block. CJEM 2013;15(6):359-370; Available at: http://www.ncbi.nlm.nih.gov/pubmed/24176460 (accessed November 25, 2013).
13. Jones, P, Chalmers, L, Wells, S, et al. Implementing performance improvement in New Zealand emergency departments: the six hour time target policy national research project protocol. BMC Health Serv Res 2012;12(1):45. doi:10.1186/1472-6963-12-45.
14. Ovens, H. ED overcrowding: the Ontario approach. Acad Emerg Med 2011;18(12):1242-1245. doi:10.1111/j.1553-2712.2011.01220.x.
15. Alberti, SG. Transforming emergency care in England. London, UK: UK Department of Health; 2004. Available at: http://aace.org.uk/wp-content/uploads/2011/11/Transforming-Emergency-Care-in-England.pdf (accessed January 29, 2015).
16. Rudd, K. New national four hour target for hospital emergency departments. Australian Government, Department of the Prime Minister and Cabinet, PM Transcripts; 2010. Available at: http://pmtranscripts.dpmc.gov.au/browse.php?did=17189 (accessed January 29, 2015).
17. British Medical Association. BMA survey of A & E waiting times. Health Policy and Economic Unit, British Medical Association. BMA House. London, UK; 2005. Available at: http://www.collemergencymed.ac.uk/code/document.asp?ID=3156 (accessed January 29, 2015).
18. HHS, Office of the Assistant Secretary Preparedness and Response (ASPR). Healthcare Preparedness Capabilities: National Guidance for Healthcare System Preparedness. Washington, DC: HHS; 2012. Available at: http://www.phe.gov/Preparedness/planning/hpp/reports/Documents/capabilities.pdf (accessed January 29, 2015).
19. Salkeld, E, Leaver, CA, Guttmann, A, et al. Barriers and facilitators to the implementation of Ontario’s emergency department clinical decision unit pilot program: a qualitative study. CJEM 2011;13(6):363-371; 10.2310/8000.2011.110380.
20. Bullard, MJ, Unger, B, Spence, J, Grafstein, E. CTAS National Working Group. Revisions to the Canadian Emergency Department Triage and Acuity Scale (CTAS) adult guidelines. CJEM 2008;10(2):136-151.
21. Bell, R, Willett, J, Oliver, J. Improving access to emergency care: addressing system issues improving access to emergency care: addressing system issues. Toronto: Ontario Hospital Association, Ontario Medical Association, Ontario Ministry of Health and Long-Term Care; 2006.
22. Ontario Ministry of Health and Long-Term Care. Ontario targets shorter ER times. 2009. Available at: http://news.ontario.ca/mohltc/en/2009/02/ontario-targets-shorter-er-times.html (accessed July 4, 2013).
23. Woodcock, T, Poots, AJ, Bell, D. The impact of changing the 4 h emergency access standard on patient waiting times in emergency departments in England. Emerg Med J 2013;30(3):e22. doi:10.1136/emermed-2012-201175.
24. Plewes, L. Accident and emergency clinical quality indicators standard specification. London; 2013. Available at: http://www.isb.nhs.uk/documents/isb-1588/amd-11-2012/1588112012spec.pdf
25. Forster, A, Rose, N, van Walraven, C, Stiell, I. Adverse events following an emergency department visit. Qual Saf Health Care 2007;16:17-22.
26. Canadian Institute of Health Information. Data Quality Study of Emergency Department Visits for 2004-2005: Volume II of IV—Main Study Findings. Ottawa; 2008.
27. Canadian Institute for Health Information. CIHI Data Quality Study of Ontario Emergency Department Visits for 2004-2005: Volume II of IV—Main Study Findings. Ottawa; 2008.
28. Canadian Institute for Health Information. National Ambulatory Care Reporting System Manual for 2011–2012. Ottawa, 2011.
29. Canadian Institute for Health Information. Discharge Abstract Database Abstracting Manual, 2011-2012 Edition. Ottawa; 2011.
30. Iron, K, Zagorski, BM, Sykora, K, Manuel, DG. Living and dying in Ontario: an opportunity for improved health information. Toronto; 2008. Available at: http://www.ices.on.ca/file/Living_and_dying_in_Ontario_March19-08.pdf
31. Canadian Institute for Health Information. Data Quality Documentation, Discharge Abstract Database—Current-Year Information, 2011–2012. Ottawa, 2011, Available at: http://www.cihi.ca/CIHI-ext-portal/pdf/internet/DAD_EXECUTIVE_SUM_11_12_EN
32. Canadian Institute for Health Information. Data Quality Documentation for External Users: National Ambulatory Care Reporting System, 2010–2011. Ottawa; 2011, Available at: http://www.cihi.ca/cihi-ext-portal/pdf/internet/nacrs_exec_summ_2010_2011_en
33. Berlin, J, Kimmel, S, Ten Have, T, Sammel, M. An empirical comparison of several clustered data approaches under confounding due to cluster effects in the analysis of complications of coronary angioplasty. Biometrics 1999;55:470-476.
34. 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):873-878. doi:10.1197/j.aem.2006.03.568.
35. Kennebeck, SS, Timm, NL, Kurowski, EM, et al. The association of emergency department crowding and time to antibiotics in febrile neonates. Acad Emerg Med 2011;18(12):1380-1385. doi:10.1111/j.1553-2712.2011.01221.x.
36. Chatterjee, P, Cucchiara, BL, Lazarciuc, N, et al. Emergency department crowding and time to care in patients with acute stroke. Stroke 2011;42(4):1074-1080. doi:10.1161/STROKEAHA.110.586610.
37. Pines, JM, Prabhu, A, Hilton, JA, et al. The effect of emergency department crowding on length of stay and medication treatment times in discharged patients with acute asthma. Acad Emerg Med 2010;17(8):834-839. doi:10.1111/j.1553-2712.2010.00780.x.
38. Hwang, U, Richardson, L, Livote, E, et al. Emergency department crowding and decreased quality of pain care. Acad Emerg Med 2008;15(12):1248-1255. doi:10.1111/j.1553-2712.2008.00267.x.
39. Mills, AM, Shofer, FS, Chen, EH, et al. The association between emergency department crowding and analgesia administration in acute abdominal pain patients. Acad Emerg Med 2009;16(7):603-608. doi:10.1111/j.1553-2712.2009.00441.x.
40. Michelson, KA, Monuteaux, MC, Stack, AM, Bachur, RG. Pediatric emergency department crowding is associated with a lower likelihood of hospital admission. Acad Emerg Med 2012;19(7): 816-820.
41. Department of Health. Special Delivery Unit Irish Department of Health. 2011. Available at: http://www.dohc.ie/about_us/divisions/special_delivery_unit (accessed July 15, 2013).
42. Cryderman, K. Health minister says Alberta won’t meet emergency room wait time targets. Calgary Herald. February 2012.
43. Technical Backgrounder for the Wait Time Alliance Report Card – June 2012. The Wait Time Alliance. Ottawa, Ontario, Canada; 2012. Available at: http://www.waittimealliance.ca/wp-content/uploads/2014/05/2012_Technical_Backgrounder.pdf (accessed January 29, 2015).
44. Rabin, E, Kocher, K, McClelland, M, et al. Solutions to emergency department “boarding” and crowding are underused and may need to be legislated. Health Aff 2012;31(8):1757-1766.
45. The Joint Commission. The Joint Commission’s new patient flow standards. Urgent Matters E-newsletter 2012;9(3):1-5.
46. Gubb, J. Have targets done more harm than good in the English NHS? Yes. BMJ 2009;338:a3130.

Keywords

Better performance on length-of-stay benchmarks associated with reduced risk following emergency department discharge: an observational cohort study

  • Michael Schull (a1) (a2) (a3) (a4), Marian Vermeulen, Astrid Guttmann (a1) (a5) (a3) (a6) and Therese Stukel (a1) (a3)

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed