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Emergency department crowding is associated with decreased quality of care for children
Marion R Sills1, Diane Fairclough, Daksha Ranade
1Department of Pediatrics, University of Colorado Denver School of Medicine, Aurora, CO, USA. marion.sills@childrenscolorado.org
Insights
Emergency department crowding negatively impacts pediatric asthma and fracture care quality. Higher patient volume and fewer care hours predict poorer outcomes, indicating a need for better crowding management.
Area of Science:
- Pediatric Emergency Medicine
- Healthcare Quality Improvement
- Hospital Operations Management
Background:
- Emergency department (ED) crowding is a growing concern in pediatric healthcare.
- Understanding the relationship between ED crowding and quality of care is crucial for patient safety and outcomes.
Purpose of the Study:
- To identify simple indicators of emergency department crowding that best predict the quality of care for pediatric patients with acute asthma and long-bone fractures.
Main Methods:
- Retrospective, cross-sectional study of pediatric patients with asthma and long-bone fractures.
- Quality of care assessed by adherence to specific care processes within one hour of arrival.
- Nine crowding measures evaluated for their association with quality of care outcomes.
Main Results:
- Rates of good quality care ranged from 23% to 64% across the five quality measures.
- Increased crowding was consistently associated with lower quality of care in both pediatric asthma and fracture cohorts.
- Total patient-care hours and the number of patients arriving in the prior six hours were the strongest predictors of reduced care quality.
Conclusions:
- Two key measures of ED crowding—total patient-care hours and recent patient arrivals—are significantly associated with lower-quality, condition-specific care for pediatric patients.
- These findings highlight the need for effective strategies to mitigate ED crowding and improve care quality in pediatric emergency settings.
Objective:
We sought to determine which of several simple indicators of emergency department crowding are most predictive of quality of care in 2 pediatric disease models: acute asthma and pain associated with long-bone fractures.
Methods:
We performed a retrospective, cross-sectional study of patients 2 to 21 years old seen for acute asthma and patients 0 to 21 years old seen for acute, isolated long-bone fractures from November 1, 2007, to October 31, 2008, at a single, academic children's hospital emergency department. The main outcome measures were quality measures based on 3 asthma care-related processes-asthma score, β-agonist, and corticosteroid-and 2 fracture-related processes-analgesic and opioid analgesic. Good quality care was defined as receipt of an indicated process within 1 hour of arrival. Poor quality care was defined as nonreceipt or delayed receipt of an indicated process. Nine crowding measures were assigned based on conditions at each patient's arrival. We calculated the adjusted risk of receiving good quality care for each quality measure at 5 percentiles of crowding for each crowding measure.
Results:
The asthma population included 927 patients, and the fracture population included 1229 patients. Among the 5 quality measures, we found rates of good quality care ranging from 23% to 64%. In adjusted models, we found an inverse association between crowding and quality. The 2 crowding measures with a consistently inverse association with the 5 quality measures across both populations were total patient-care hours and number arriving in prior 6 hours. Across the 10 models combining 1 of 2 key crowding variables with 1 of 5 quality measures, patients in the 2 populations were 0.40 (95% confidence interval, 0.27-0.55) to 0.78 (confidence interval, 0.71-0.85) times as likely to receive the indicated care process within 1 hour when each crowding measure was at the 75th than at the 25th percentile.
Conclusions:
Two measures of ED crowding are consistently associated with lower-quality asthma- and fracture-specific care in the ED for pediatric patients.
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