Elsevier

Annals of Emergency Medicine

Volume 50, Issue 5, November 2007, Pages 501-509.e1
Annals of Emergency Medicine

Health policy and clinical practice/original research
Effect of Emergency Department Crowding on Time to Antibiotics in Patients Admitted With Community-Acquired Pneumonia

Presented at the Society for Academic Emergency Medicine annual meeting, May 2006, San Francisco, CA.
https://doi.org/10.1016/j.annemergmed.2007.08.003Get rights and content

Study objective

We hypothesize that emergency department (ED) volume and increased patient complexity are associated with lower quality of care, as measured by time to antibiotics for patients being admitted with community-acquired pneumonia.

Methods

This was a cross-sectional study at a university tertiary care hospital ED. Community-acquired pneumonia patients admitted from the ED and discharged between January 2004 and June 2005 were reviewed by our institution for The Joint Commission’s antibiotic timing core measure. Medical records were abstracted for patient age, sex, race, mode of transport, arrival time, triage acuity, inpatient level of care, and arrival-to-antibiotic-administration times. Controlling for patient characteristics, multivariate logistic regression determined association of antibiotic administration within 4 hours of arrival, with total ED volume at the time of the community-acquired pneumonia patient’s arrival, and with number of ED patients requiring admission at the time of arrival.

Results

Four hundred eighty-six patients were eligible for the study; antibiotic administration time was available for 405. Sixty-one percent of patients received antibiotics within 4 hours. Antibiotic administration within 4 hours was less likely with a greater number of patients (odds ratio 0.96 per additional patient; 95% confidence interval 0.93 to 0.99) and a greater number of patients ultimately admitted (odds ratio 0.93 per patient; 95% confidence interval 0.88 to 0.99) in the ED. The effect of additional patients was present below total ED capacity.

Conclusion

As ED volume increases, ED patients with community-acquired pneumonia are less likely to receive timely antibiotic therapy. The effect of additional patients appears to occur even at volumes below the maximum bed capacity. Measures to ensure that quality targets are met in the ED should consider the impact of ED volume.

Introduction

Emergency department (ED) crowding has been postulated as a potential cause of poor quality patient care.1 Several reports in the lay press have claimed that EDs are often unsafe because of crowding.2, 3, 4, 5, 6, 7, 8 According to The Joint Commission (TJC), more than half of all “sentinel event” cases of morbidity and mortality as a result of delays in treatment occur in EDs, with ED crowding cited as a contributing factor in 31%.9 To date, however, there have been limited published scientific data to support this statement.10, 11, 12, 13, 14, 15, 16

There were more than 16 million admissions to US hospitals initiated in EDs in 2003, representing 55% of all admissions, excluding pregnancy and childbirth.17 The most frequent reason for admission from an ED was pneumonia, with 935,000 admissions (5.7% of admissions through an ED). Community-acquired pneumonia was one of the initial areas identified by TJC as a hospital core measure for quality of care, with a target of 8 hours. A large retrospective study using a 1998 to 1999 Centers for Medicare & Medicaid Services (CMS) data set found that administration of antibiotics to patients 65 years or older, admitted with pneumonia within 4 hours of hospital arrival, was associated with improved inhospital and 30-day mortality.18 Subsequently, CMS and TJC revised their core measure to create a target of receiving initial antibiotics within 4 hours of hospital arrival.

EDs are being closely scrutinized for their ability to meet the 4-hour antibiotic target, as well as other quality benchmarks, yet the impact of their volume is often not recognized. Demonstrating a relationship between volume and quality of care is important in bringing resources to bear on solving the crowding issue, as well as improving the ability to meet quality benchmarks. Additionally, if ED volume affects performance on measures of quality of care, EDs may need to revise their operations to meet the growing challenge of delivering time-sensitive treatments for trauma, sepsis, stroke, and acute coronary syndrome patients.

The purpose of this study is to determine whether there is an association between ED volume and timing of antibiotic administration in patients admitted to the hospital through the ED with community-acquired pneumonia. We hypothesize that antibiotic delay is associated with higher ED volume and, in particular, a higher volume of ED patients requiring hospital admission.

Section snippets

Study Design

This is a cross-sectional study of patients who were admitted through a university tertiary care hospital ED and discharged from an inpatient hospitalization for pneumonia between January 1, 2004, and June 30, 2005. We analyzed the effect of each additional patient present in the ED at the community-acquired pneumonia patient’s arrival on the odds of the community-acquired pneumonia patient receiving antibiotics within 4 hours.

Setting

The ED has an annual census of 39,000 patients, with 29 beds, and is

Characteristics of Study Subjects

A total of 898 patients were discharged from our hospital with a primary or secondary diagnosis of community-acquired pneumonia during the study period (Figure 1). Seven hundred thirty-one patient visits met eligibility criteria for measure PN-5b and were chosen for review. Four hundred eighty-six (66.5%) had no PN-5b exclusion criteria and were admitted through the ED. Antibiotic delivery time was unavailable for 81 patients from this group, leaving a final sample of 405 for review (45% of all

Limitations

This is a cross-sectional, single-center study, and the findings may not apply to other settings. The study sample included every admitted pneumonia patient from January through December 2004 and a random sample thereafter. Although this was a mixed sample of randomly selected patients for some quarters and all patients for others, we do not see how this might have biased our results in one particular direction. Door to antibiotic time was unavailable in 16.7% of the ED cohort. However, we do

Discussion

In this study, we found that a greater number of patients in the ED is associated with delayed administration of antibiotics for ED patients with community-acquired pneumonia, which was apparent on univariate analysis and remained similar when controlled for other factors in a multivariate model. We also found that having more admitted patients in the ED was associated with delayed antibiotic administration. Although we found that patients with a more urgent triage acuity and those admitted to

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  • Cited by (0)

    Supervising editor: J. Stephan Stapczynski, MD

    Michael L. Callaham, MD, has recused himself from the review and any decisionmaking on this article.

    Earn CME Credit: Continuing Medical Education for this article is available at: www.acep.org/AnnalsCME.

    Author contributions: CF and EJW conceived and designed the study. CF and CAM collected the data. CF, EJW, CAM, and PB drafted the article. CF, EJW, CM, and PB contributed substantially to its revision. CF takes responsibility for the paper as a whole.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.

    Reprints not available from the authors.

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