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ER crowding tied to higher in-hospital death rates

By Kerry Grens

NEW YORK (Reuters Health) - Patients admitted to the hospital on days when the emergency department is overcrowded are slightly more likely to die than patients admitted on other days, according to a new study.

"We are suggesting that one reason for this association is, when you have a crowded hospital or emergency department, that the quality of care is not as good, that there are delays in diagnosis, there are delays in treatment, and all these things add up so that for a small set of patients this actually makes a difference in whether they survive or don't survive," said Dr. Benjamin Sun, lead author of the study and an associate professor at Oregon Health & Science University.

Emergency room crowding is a known problem in the U.S., and previous research has shown it to be linked with harmful effects.

One study published last year found that when ambulances are diverted away from a crowded ER, as many as three in 100 heart attack patients die unnecessarily.

In the latest study, Sun and his colleagues wanted to look at the impact on all types of patients, instead of just one condition.

They used the same indicator of ER crowding, ambulance diversion, to determine the days when the department was over capacity.

They then looked at all the patients who were admitted through the emergency department at 187 California hospitals during one year, 2007.

In all, this included nearly 1,000,000 admissions, 20 percent of which happened on days when ambulances were diverted away from that hospital, and 80 percent on days when the hospital accepted all ambulances.

Sun's group reports in the Annals of Emergency Medicine that 3.9 percent of patients admitted on the overcrowded days ended up dying in the hospital, while 3.6 percent of patients died on the other days.

After taking into account how sick the patients were, the researchers determined that being admitted at times when the ER was overcrowded was tied to a five percent increase in dying before being discharged.

Dr. Adam Singer, an emergency medicine professor at Stony Brook University, said he's not surprised by the results.

"More and more studies keep validating what we already knew. This is another study showing (crowding) is a bad thing and it needs to be solved," he told Reuters Health.

Singer said the problem stems not from dysfunction in the ER, but an inability to move patients onto hospital floors once they are admitted.

Patients then fill up the ER waiting for a room and being neglected.

"Patients are getting less care and are getting ignored by staff," Singer said. "Once we've seen a patient we know needs to be admitted, we move on."

Singer and his colleagues have developed measures he says have worked to streamline the movement of patients through the ER.

On especially busy days, the staff will have patients who need a room wait in the hallways of the hospital wards, rather than in the ER.

Sun pointed out that other hospitals will post ER wait times on billboards.

"This could give patients more information on which places have more crowding, but for most patients that's not an option," he told Reuters Health.

Another way to address crowding, Sun said, is to make sure that elective procedures are scheduled throughout the week, rather than having them bunch up on a few days and fill up hospital beds.

Numerous leading medical organizations, such as the Institute of Medicine and the Institute for Healthcare Improvement, have recognized that crowding in emergency rooms is a serious problem.

And the federal Agency for Healthcare Research and Quality has developed a step-by-step guide for hospital administrators to address the causes of overcrowding (http://1.usa.gov/Z2M1Mb).

Singer said that despite a good understanding of the hazards of an overflowing ER, the challenge persists because many see it as an emergency room problem, and not a hospital-wide issue.

"We need to go from describing the problem to solving the problem," he said.

SOURCE: http://bit.ly/ZkCNcZ Annals of Emergency Medicine, online December 10, 2012.

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