An Independent Evaluation of Four Quantitative Emergency Department Crowding Scales

Background Emergency department (ED) overcrowding has become a frequent topic of investigation. Despite a significant body of research, there is no standard definition or measurement of ED crowding. Four quantitative scales for ED crowding have been proposed in the literature: the Real‐time Emergency Analysis of Demand Indicators (READI), the Emergency Department Work Index (EDWIN), the National Emergency Department Overcrowding Study (NEDOCS) scale, and the Emergency Department Crowding Scale (EDCS). These four scales have yet to be independently evaluated and compared. Objectives The goals of this study were to formally compare four existing quantitative ED crowding scales by measuring their ability to detect instances of perceived ED crowding and to determine whether any of these scales provide a generalizable solution for measuring ED crowding. Methods Data were collected at two‐hour intervals over 135 consecutive sampling instances. Physician and nurse agreement was assessed using weighted κ statistics. The crowding scales were compared via correlation statistics and their ability to predict perceived instances of ED crowding. Sensitivity, specificity, and positive predictive values were calculated at site‐specific cut points and at the recommended thresholds. Results All four of the crowding scales were significantly correlated, but their predictive abilities varied widely. NEDOCS had the highest area under the receiver operating characteristic curve (AROC) (0.92), while EDCS had the lowest (0.64). The recommended thresholds for the crowding scales were rarely exceeded; therefore, the scales were adjusted to site‐specific cut points. At a site‐specific cut point of 37.19, NEDOCS had the highest sensitivity (0.81), specificity (0.87), and positive predictive value (0.62). Conclusions At the study site, the suggested thresholds of the published crowding scales did not agree with providers' perceptions of ED crowding. Even after adjusting the scales to site‐specific thresholds, a relatively low prevalence of ED crowding resulted in unacceptably low positive predictive values for each scale. These results indicate that these crowding scales lack scalability and do not perform as designed in EDs where crowding is not the norm. However, two of the crowding scales, EDWIN and NEDOCS, and one of the READI subscales, bed ratio, yielded good predictive power (AROC >0.80) of perceived ED crowding, suggesting that they could be used effectively after a period of site‐specific calibration at EDs where crowding is a frequent occurrence.     

Influenza‐associated delays in patient throughput and premature patient departure in emergency departments in New South Wales,Australia: A time series analysis

Objectives

Influenza outbreaks cause overcrowding in EDs. We aimed to quantify the impact of influenza on the National Emergency Access Targets and premature patient departure in New South Wales, Australia.

Methods

This was a retrospective observational study of 11 million presentations to 115 hospitals during 2010–2014, using routinely collected administrative records. A time series generalised additive regression model was used to assess the correlation between weekly influenza activity and the weekly proportion of patients leaving the ED in >4 h and the proportion that departed before commencing or completing treatment (‘did not wait’), after controlling for background winter and holiday effects.

Results

During 2011–2014, peak annual circulating influenza was associated with the peak weekly proportion of presentations that left in >4 h. The maximum estimated absolute weekly change in that proportion was 3.88 (95% confidence interval 3.02–4.74) percentage points in 2014. For presentations that did not wait, influenza circulation was associated with statistically significant increases in all years, with a maximum weekly value of 2.68 (95% confidence interval 2.31–3.06) percentage points in 2012.

Conclusions

Circulating influenza was associated with sustained increases and peaks in delayed patient throughput and premature patient departures. Influenza surveillance information may assist with development of health system and hospital workforce planning and bed management activities.     

伴上颌拥挤的成人骨性反(牙合)正畸矫治的临床研究

目的:评价采用拔除上下颌4个前磨牙矫治伴上颌拥挤的骨性反病例的临床效果,为临床矫治该类骨性反牙合提供一种新思路。方法:选取17～30岁伴上颌拥挤的骨性反牙合病例13例,拔除上、下颌4个第一或第二前磨牙,应用标准方丝弓固定矫治技术,分析治疗前后X线头颅侧位片各项指标变化。结果:所有病例在矫治结束后磨牙尖牙均达到Ⅰ类关系,覆牙合覆盖正常。患者硬组织改变没有显著性(p≥0.05)。L1-MP角平均减小8.4°,U1-L1角平均增大11.7°,L1-NB角平均减小10.1°,L1-NB距平均减小5.2mm,差异均有显著性(p<0.01)。软组织侧貌改善明显,Li-E距、Li-H距、Li-RL2距平均减小量分别为3.3mm、3.3mm和4.5mm,差异均有显著性(p<0.01)。结论:采用拔除4个前磨牙的方法矫治伴上颌拥挤的骨性反牙合病例是一种可尝试的矫治方法,矫治后咬合关系良好,侧貌变为直面型。     

The Effect of Emergency Department Crowding on Analgesia in Patients with Back Pain in Two Hospitals

Objectives: The authors assessed the association between measures of emergency department (ED) crowding and treatment with analgesia and delays to analgesia in ED patients with back pain. Methods: This was a retrospective cohort study of nonpregnant patients who presented to two EDs (an academic ED and a community ED in the same health system) from July 1, 2003, to February 28, 2007, with a chief complaint of “back pain.” Each patient had four validated crowding measures assigned at triage. Main outcomes were the use of analgesia and delays in time to receiving analgesia. Delays were defined as greater than 1 hour to receive any analgesia from the triage time and from the room placement time. The Cochrane‐Armitage test for trend, the Cuzick test for trend, and relative risk (RR) regression were used to test the effects of crowding on outcomes. Results: A total of 5,616 patients with back pain presented to the two EDs over the study period (mean ± SD age = 44 ± 17 years, 57% female, 62% black or African American). Of those, 4,425 (79%) received any analgesia while in the ED. A total of 3,589 (81%) experienced a delay greater than 1 hour from triage to analgesia, and 2,985 (67%) experienced a delay more than 1 hour from room placement to analgesia. When hospitals were analyzed separately, a higher proportion of patients experienced delays at the academic site compared with the community site for triage to analgesia (87% vs. 74%) and room to analgesia (71% vs. 63%; both p < 0.001). All ED crowding measures were associated with a higher likelihood for delays in both outcomes. At the academic site, patients were more likely to receive analgesia at the highest waiting room numbers. There were no other differences in ED crowding and likelihood of receiving medications in the ED at the two sites. These associations persisted in the adjusted analysis after controlling for potential confounders of analgesia administration. Conclusions: As ED crowding increases, there is a higher likelihood of delays in administration of pain medication in patients with back pain. Analgesia administration was not related to three measures of ED crowding; however, patients were actually more likely to receive analgesics when the waiting room was at peak levels in the academic ED. ACADEMIC EMERGENCY MEDICINE 2010; 17:276–283 © 2010 by the Society for Academic Emergency Medicine     

The etiology of medical gridlock: Causes of emergency department overcrowding in New York City

Overcrowding of emergency departments in New York City is the most apparent symptom of a crumbling health care system. There is a growing need for the care of a largely impoverished population suffering from an increasing prevalence of AIDS, substance abuse, and psychiatric disease. Institutions crippled by critical shortages of inpatient beds and nurses lack the resources to meet this rising demand. Although the epidemic of medical gridlock began in New York City, it is spreading rapidly to involve other areas of the country. Short-term efforts to resolve this crisis have thus far been unsuccessful. Long-range solutions are likely to be costly and may require a reconfiguration of societal health care priorities.     

Ambulance diversion is not associated with low acuity patients attending Perth metropolitan emergency departments

Objective: To examine the relationship between ambulance diversion and low acuity patient (LAP) attendances to EDs. Methods: Comparison of LAP attendance rates at inner metropolitan EDs and outer metropolitan EDs using a previously validated methodology. Results: The percentage of LAP attendances was lower at inner metropolitan EDs (11.4%, 95% CI 11.3–11.6) compared to outer metropolitan hospitals (22.9%, 95% CI 22.6–23.2, P < 0.001). The proportion of LAP attendances was slightly higher at both inner and outer metropolitan hospitals after‐hours compared to working hours. Average daily LAP attendances per inner metropolitan hospital (13.4 attendances, 95% CI 13.2–13.6) which averaged 89.2 min of diversion daily (95% CI 88.7–89.7) were lower than at outer metropolitan hospitals (19.3 attendances, 95% CI 19.0–19.6, P < 0.001), which averaged 12.4 min of diversion daily (95% CI 12.1–12.5, P < 0.001). Conclusions: Inner metropolitan hospitals experience low LAP attendance rates. Attempts to further reduce LAP attendance rates at Perth inner metropolitan hospitals have limited scope to reduce ambulance diversion.