Study Directly Correlates Emergency Department Crowding with Poor Quality Care

(Adapted from American College of Emergency Physicians news release) Emergency department crowding, which has been cited as a potential cause of compromised patient care, increases the length of time that pneumonia patients must wait for antibiotics, sometimes to the point where they do not receive them at all, and contributes to long delays in or even lack of treatment for patients with severe pain. Three studies in the Annals of Emergency Medicine support the theory that emergency departments are often unsafe due to crowding. "The Joint Commission and the Centers for Medicare and Medicaid Services (CMS) have established, as one of their core measures of quality care, that patients with pneumonia should receive antibiotics within four hours of arriving at the hospital, but crowded emergency departments have a very difficult time meeting that standard." said Christopher Fee, MD, assistant clinical professor medicine, Division of Emergency Medicine at UCSF. "This measure was based on a study that demonstrated that elderly Medicare pneumonia patients receiving antibiotics within four hours had better in-hospital and 30-day survival rates. Our study shows that even a small increase in emergency department crowding can make it difficult or impossible for that standard to be satisfied, simply because we can't get to our patients in a timely fashion. One of the most frequent reasons for hospital admission from the emergency department is pneumonia, and it seems that a lot of patients are not getting what they need when they need it." In Fee's study, only 61 percent of patients received antibiotics within four hours. For each additional patient present in the emergency department at the time of the pneumonia patient's arrival, the odds of receiving antibiotics within the four-hour window decreased by four percent. Furthermore, the study suggests that this effect begins to occur even before the maximum bed capacity has been reached. "The Joint Commission and CMS need to acknowledge the impact of emergency department crowding on the quality of care provided to our patients and work with healthcare organizations to promote changes that will alleviate contributing factors such as the lack of access to primary care physicians, boarding of psychiatric patients due to lack of inpatient psychiatric facility capacity and the practice of boarding admitted patients in the emergency department," said Fee. "The model of using the emergency department as the overflow vessel for the hospital is broken. The vessel is overflowing and there is nowhere else to go." "These studies provide more evidence that when the emergency department is crowded, patients do not receive optimal care, either for pneumonia or for severe pain," said Judd E. Hollander, MD, president of the Society for Academic Emergency Medicine. "Emergency department crowding is a public health crisis in the United States. The systematic inefficiencies that cause emergency department crowding make care worse for patients with pneumonia and allow patients with severe pain to suffer. Just imagine how crowding-related delays could hinder treatment for trauma, stroke and heart attack, never mind in the event of disaster or terrorism."

Effect of Emergency Department Crowding on Time to Antibiotics in Patients Admitted With Community-Acquired Pneumonia Christopher Fee, Ellen J. Weber, Carley A. Maak, Peter Bacchetti Annals of Emergency Medicine, published online October 3, 2007 Abstract | Full Text | Full Text (PDF)

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