Written by Clay Smith
Spoon Feed
ED crowding was associated with markedly increased odds of 10-day mortality in lower acuity patients who were discharged home.
Why does this matter?
ED crowding may increase mortality in critically ill patients. But what about lower acuity patients sent home during periods of overcrowding?
Crowding our judgment
This was a retrospective look at a large ED registry with over 700,000 patients to determine the effect of ED crowding on 10-day mortality in patients who were ESI acuity 3-5 and were discharged home. Patients in this group who were discharged and died within 10 days (0.09%) tended to be older, ESI 3 (vs 4 or 5), and had more comorbidities. Specifically related to crowding, odds of short-term death was nearly 6 times greater when the ED length of stay was 8 vs 2 hours (aOR 5.86; 95%CI 2.15 to 15.94). ED occupancy ratio in the upper quartile (compared to the lowest quartile) was associated with a 53% increased odds of early mortality (aOR 1.53; 95% CI 1.15 to 2.03). What I take away is that crowding may cloud our judgment. Someone we might ordinarily admit may seem more appropriate for discharge if we know they will continue to take up an ED bed as a boarder. Be especially cautious before sending elderly, level 3 patients with a load of medical problems home.
Source
Associations Between Crowding and Ten-Day Mortality Among Patients Allocated Lower Triage Acuity Levels Without Need of Acute Hospital Care on Departure From the Emergency Department. Ann Emerg Med. 2019 Jun 19. pii: S0196-0644(19)30331-2. doi: 10.1016/j.annemergmed.2019.04.012. [Epub ahead of print]
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Reviewed by Thomas Davis
I would also like to add, nursing bias seems to play a role in this phenomenon in my facility. The triage ESI levels change drastically when the ED is crowded. Old people with belly pain but grossly abnormal VS end up a level 3 instead of a 2 when the ED is crowded so nursing staff can return patients to the waiting room for a longer duration. In addition, I suspect another confounding etiology is that patients in crowded EDs with longer duration LOS tend to suggest leaving AMA. They quickly decide they’d rather do anything than stay in a crowded hospital any longer; thus, they leave more often against medical advice or are discharged home after being recommended for observation. I would be curious what those rates are retrospectively in this study.