The relationship between emergency department crowding and outcome of referred critical patients from other hospitals

© 2017 The Authors; Tabriz University of Medical Sciences This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The relationship between emergency department crowding and outcome of referred critical patients from other hospitals

Citation: Ala A, Shams-Vahdati S, Fahimi R. The relationship between emergency department crowding and outcome of referred critical patients from other hospitals.J Anal Res Clin Med 2017; 5(4): 118-21.Doi: 10.15171/jarcm.2017.023 Crowding of emergency department has become a public health crisis and an international health issue for more than 20 years.Its effect on productivity, patients' satisfaction, and medical errors have been studied extensively.It is a growing concern in many countries all over the world, representing a serious problem in emergency departments (EDs).Emergency physicians have identified crowding in ED as a critical threat to the treatment and emergency care quality. 1,2n the Centers for Medicare and Medicaid Services (CMS), long length of stay (LOS) in the ED is associated with treatment delays, wrong diagnosis, low-quality cure, patients leaving without being seen or getting complete treatment steps, ambulance diversion, and finally low patients' satisfaction.
][5][6][7] Even tiny effects of ED crowding on patients' safety may have large aggregate effects.Several studies reported that crowding of J Anal Res Clin Med, 2017, 5(4), 118-21.doi: 10.15171/jarcm.2017.023,http://journals.tbzmed.ac.ir/JARCM emergency department leads to high mortality rate and worse patients' outcomes. 8iven the importance of ED crowding, as a major threat to public health, in this study, we aimed to assess the relationship of ED crowding and subsequent outcomes in a general population of ED.
In this retrospective cross-sectional study, 583 patients who have referred to the ED of Imam Reza Hospital, from 22 September 2016 until 22 March 2017 were studied.Patients were considered as the first and second triage emergency severity index (ESI) level.Triage ESI level one was defined for all the patients who needed life-saving measures.This ESI level included patients with cardiac arrest, respiratory distress, low O2 saturation (less than 90%), traumatic patients with no response to painful stimuli and respiratory rate < 6 per minute.Triage ESI level two was defined for all the patients who did not need life-saving measures.However, it was not possible to postpone their visits and two main steps should have been done: 1) checking vital signs, 2) immediate nursing measures.
Crowded times with the most referral patients attending to the ED of Imam Reza hospital during our study was supposed to be 3:00 pm till 11:00 pm.
Patients who had expired for any reason before entering to the ED or the ones in other levels of triage were excluded.Outcome, mortality rate and crowding based on numbers of referral patients per hour were assessed.All data were reported in the prepared forms and then analyzed.Statistical analysis was done by SPSS software (version 15, SPSS Inc., Chicago, IL, USA), and the data were analyzed by descriptive format for demographic and descriptive data.Student's independent t-test was used for comparison of quantitative data between the groups.P less than 0.050 was considered meaningful.
In our study, 583 patients were studied with the mean ± standard deviation (SD) age of 49.5 ± 25.0 years.The youngest was 2 years old, whereas the oldest patient was 92 years old.56.4% (329) of them were men and 43.6% (254) were women.About 43.2% (252) of patients were referred to the ED in crowded times.
53.5% (312) of patients were referred to the ED in winter and 46.5% (271) referred to the ED in warm months of the year.
Mean ± SD of systolic blood pressure (SBD) and diastolic blood pressure (DBP) were 126.6 ± 27.8 and 76.1 ± 14.8 respectively, in which minimum and maximum of SBP were 70 and 200 mmHg.The minimum and maximum of DBP were 50 and 110 mmHg.
The mean ± SD of pulse rate (PR) of patients was 89.49 ± 19.1 with the minimum of 38 and maximum of 180 beats per minute.The mean ± SD of respiratory rate (RR) was 16.9 ± 3.4, in which minimum RR was 10 and maximum was 32 breathes per minute.The mean ± SD of body temperature (BT) was 36.96 ± 0.40.The lowest BT was 36 °C and highest was reported 38 °C.
The mean ± SD of length of stay in ED was 239.6 ± 233.0 minutes, with a minimum of 7 minutes and maximum of 900 minutes.There was a statistically significant association between crowding of ED and mortality rate.In Cha et al. study, 46.3% were women and 53.7% were men and the mean age was 47 years. 14In our study and similar to other studies, a number of men patients referring to the ED was higher than women patients which indicates their involvement in serious and high-risk occupations.The mean age of many studies is more than 50 years, demonstrating their relative reduction in quality of body habitus, and appropriate reactions to the dangers in this age.In our study, the mean SBP, DBP, PR, RR, BT, were 120.60 ± 27.80 mmHg, 70.09 ± 14.80 mmHg, 89.49 ± 19.10 beats per minute, 16.88 ± 3.40 breathes per minute, and 36.96± 0.42 degrees, respectively.In Schenkel study the average BP was 59.4 ± 16.2, PR was 89.1 ± 24.6 pulses per minute, and BT was 36.5 ± 1.2. 9ital sign of patients referring to the ED depends on their diagnosis (trauma, cardiovascular disease, stroke, sepsis and etc.).Even patients' vital sign can change season by season, so differences in vital sign can be justified.In our study, 5.53% (312) were referred to the ED in cold days of the year, which could be due to the high prevalence of cardiovascular and respiratory disease in winter.In our study, duration of admitting in ED was 239.6 ± 233.0 minutes (4 hours).In another study, duration of physician initial assessment was 122.3 minutes in nonmonitoring beds. 10In Pines study, duration of staying in ED was 10.8 hours. 12In Nasr-Esfahani et al. 13 and in Cha et al. 14 studies, duration of staying in ED was 10.4 ± 5.5 and 8 hours, respectively.The mean duration of hospitalization in our study was lower than others showing an advantage of ED of Imam Reza Hospital of Tabriz, Iran.It represents correct and immediate triage, expert medical workers, advanced and available diagnostic agents, expert physicians, and adequate emergency and hospital facilities.According to the hours of referring to the ED, in our study 43.2% (252) patients were referred during crowded times.Also, 6.2% (126) expired, and the final outcome of 1.3% (54) of patients admitted to the wards was death.
Increasing the number of patients can affect the mean time of the first visit by physicians. 15he general mortality rate in the ED and those who were admitted was 8.30%.In Schenkel study, the mortality rate was 14.6%. 9In Pines study, 44% were referred in the peak hours (3 pm to 11 pm) to the ED. 12 In O'Connor et al. study, 52% were referred to the ED during peak hours. 10In our study, the mortality rate was relatively higher than other similar studies, which may be due to including critical patients with higher mortality rate in our study.Moreover, poor treatment facilities could be another potential reason.Improved treatment equipment would definitely promote diagnostic and therapeutic procedures.Results indicate a high percentage of mortality rates in rush hours.Our studies and other similar studies show that by increasing the number of patients admitting to the ED, final outcome (mortality) gets worse.
By increasing the number of patients and overcrowding in ED, the outcome gets poor with an increased mortality rate.Special thanks to Imam Reza hospital staffs for their kind help.
Study design and supervision: Alireza Ala; analyzing and critical review: Samad Shams-Vahdati; data gathering and writing: Roshan Fahimi.

Table 1 .
Frequency and comparison of patients' outcome between rush and no rush time