ED crowding is associated with an increased time to pneumonia treatment

doi:10.1016/j.ajem.2009.06.023

The American Journal of Emergency Medicine

Volume 28, Issue 7, September 2010, Pages 809-812

https://doi.org/10.1016/j.ajem.2009.06.023 Get rights and content

Abstract

Objective

We measured the correlation between emergency department (ED) occupancy rate and time to antibiotic administration for patients with pneumonia treated in a community hospital setting.

Methods

We reviewed quality improvement data on patients treated for pneumonia in our ED and admitted over a 5-month period. The outcomes were timeliness of antibiotic therapy (within 4 hours of arrival) and overall time to antibiotic administration. Emergency department crowding was measured as the ED occupancy rate. We calculated (1) the Spearman correlation between occupancy rate at time of patient presentation and the time to antibiotic administration, (2) the odds ratio of receiving antibiotics within 4 hours with increasing ED occupancy, and (3) the ability of the occupancy rate to predict failure of achieving the 4-hour goal with the receiver operating characteristic curve.

Results

A total of 334 patients were treated over the study period, of which 262 had complete data available. Occupancy rate ranged from 20% to 245%, and median was 137%. Eighty-one percent received antibiotics within 4 hours; the median time was 150 minutes. Time to antibiotics showed a positive correlation with occupancy rate (Spearman ρ = 0.17, P = .008). An increasing ED occupancy rate was associated with decreased odds of receiving antibiotics within 4 hours (odds ratio, 0.31; 95% confidence interval, 0.13-0.75). Receiver operating characteristic curve area was 0.62 (95% confidence interval, 0.54-0.70; P = .009).

Conclusion

Emergency department occupancy rate was associated with increased time to antibiotic treatment for patients admitted with pneumonia. Occupancy rate had fair success in predicting failure of treatment within 4 hours.

Introduction

The Institute of Medicine has identified a growing crisis in the provision of care within the emergency department (ED). This national problem has its fundamental roots in hospital and ED crowding [1]. Emergency department crowding has been associated with an increased risk of death or disability [2], [3], [4], [5], delays in treatment of patients with suspected acute myocardial infarction [6], decreased performance on pneumonia quality-of-care measures [7], transport delays, ambulance diversion, and patients leaving without being seen by a physician [8]. These quality-of-care and safety issues also directly impact the public perception of care and the decisions of purchasers. Publicly reported measures, specifically with respect to treatment of ED patients admitted with pneumonia, have been shown to be affected by ED crowding. For patients with community-acquired pneumonia, a recent analysis performed at a university tertiary care hospital found that increased ED volume was associated with a decreased likelihood of timely antibiotic therapy [9], whereas a study at an urban academic ED found a substantial impact of ED crowding on time to antibiotics [10]. It is uncertain if this relationship holds in community hospitals, where operational factors may vary and most admitting physicians are in private practice.

The demonstration that ED crowding affects the timeliness of antibiotic treatment for patients with pneumonia in a variety of clinical settings would validate the scope and breadth of the problem of ED crowding. Given the large number of US patients who obtain care at community hospitals, such demonstration in a community hospital ED would provide additional impetus for improvement and change.

We sought to measure the correlation between the ED occupancy rate and the time to antibiotic administration for patients with pneumonia in a community hospital ED. We hypothesized that increased crowding would show a positive correlation with time to treatment.

Section snippets

Study design, setting, and selection of participants

We performed a retrospective review of all adult patients older than 18 years treated for pneumonia over a 5-month period from October 1, 2007, through February 29, 2008. The study setting was our tertiary care suburban community hospital that has approximately 85,000 ED visits annually and 700 inpatient beds. Although the hospital has both internal medicine and family practice residency training programs, most patients are admitted to, and cared for by, private practice physicians without

Results

A total of 334 patients were treated for pneumonia over the study period and were therefore eligible for this analysis. Out of these 334 patients, 262 had complete data available. The most commonly missing data element was the occupancy rate at time of admission, which was missing for 20 days in October and 20 days in November because of a server malfunction.

Out of 262 patients, 214 (81.7%; 95% confidence interval [CI], 76.5%-86.2%) received antibiotics within 4 hours, whereas 48 patients did

Discussion

This analysis identified a positive association between time to antibiotic treatment for patients admitted with pneumonia and ED crowding, as measured by ED occupancy rate. An ED occupancy rate greater than the median was associated with an increased likelihood of failure to administer antibiotics within 4 hours of arrival.

The results of this study, within a community hospital, confirm findings from urban, academic medical centers. In one study of patients admitted with community-acquired

Limitations

This is a retrospective review of patients with a primary admitting diagnosis of pneumonia. Individuals with a secondary admitting diagnosis of pneumonia could not be captured in this analysis and are not included because secondary diagnoses are not entered into the electronic registry. The time to treatment for patients with secondary admitting diagnoses of pneumonia is unknown.

We did not attempt to control for patient characteristics in our analysis. This analysis did not examine the impact

Conclusions

In summary, our analysis identified a significant correlation between ED occupancy rate and failure to receive antibiotics within 4 hours of patient arrival. These results add to the growing evidence of the negative impact of ED crowding on quality of care. Future research should examine specific process steps that are affected by increased ED occupancy so barriers may be anticipated and removed.

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Citation Excerpt :
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: Presented at the American College of Emergency Physicians Research Forum held in Chicago, IL, October 2008.

^☆: No outside funding or support was received.

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Brief ReportED crowding is associated with an increased time to pneumonia treatment☆

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Study design, setting, and selection of participants

Results

Discussion

Limitations

Conclusions

Ann Emerg Med

Ann Emerg Med

Hospital-based emergency care: at the breaking point

The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments

Med J Aust

Increase in patient mortality at 10 days associated with emergency department overcrowding

Med J Aust

Brief Report
ED crowding is associated with an increased time to pneumonia treatment☆