Pediatrics/original research
Emergency Department Crowding Is Associated With Decreased Quality of Care for Children With Acute Asthma

Presented as an abstract at the Pediatric Academic Societies annual meeting, May 2006, San Francisco, CA, May 2008, Honolulu, HI, May 2009, Baltimore, MD, and May 2010, Vancouver, British Columbia, Canada; the Agency for Healthcare Research and Quality 2008 Conference: Promoting Quality, Partnering for Change, September 2008, Bethesda, MD; and the American College of Emergency Physicians Scientific Assembly, October 2008; Chicago, IL.
https://doi.org/10.1016/j.annemergmed.2010.08.027Get rights and content

Study objective

We seek to determine which dimensions of quality of care are most influenced by emergency department (ED) crowding for patients with acute asthma exacerbations.

Methods

This cross-sectional study with retrospective data collection included patients aged 2 to 21 years treated for acute asthma during November 2007 to October 2008 at a children's hospital ED. We studied 3 processes of care—asthma score, β-agonist, and corticosteroid administration—and 9 quality measures representing 3 quality dimensions: timeliness (1-hour receipt of each process), effectiveness (receipt/nonreceipt of each process), and equity (language, identified primary care provider, and insurance). Primary independent variables were 2 crowding measures: ED occupancy and number waiting to see an attending-level physician. Models were adjusted for age, language, insurance, primary care access, triage level, ambulance arrival, oximetry, smoke exposure, and time of day. For timeliness and effectiveness quality measures, we calculated the adjusted risk of each quality measure at 5 percentiles of crowding for each crowding measure and assessed the significance of the adjusted relative interquartile risk ratios. For equity measures, we tested their role as moderators of the crowding-quality models.

Results

The asthma population included 927 patients. Timeliness and effectiveness quality measures showed an inverse, dose-related association with crowding, an effect not moderated by equity measures. Patients were 52% to 74% less likely to receive timely care and were 9% to 14% less likely to receive effective care when each crowding measure was at the 75th rather than at the 25th percentile (P<.05).

Conclusion

ED crowding is associated with decreased timeliness and effectiveness—but not equity—of care for children with acute asthma.

Introduction

Studies of adult populations have shown emergency department (ED) crowding to be both widespread1, 2, 3, 4 and a threat to quality.5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 The Institute of Medicine defines quality by 6 dimensions: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.22 A recent review of quality dimensions and ED crowding in adult populations showed inverse associations (decreased quality associated with increased crowding) across all dimensions studied.23 To our knowledge, no previous studies have explored the crowding-quality relationship in an ED population of children. One barrier to modeling the association between crowding and an array of quality dimensions in children is the scarcity of quality measures applicable to children in the ED setting.24, 25, 26 The 2 most commonly examined quality measures in studies of adult ED crowding—acute myocardial infarction and pneumonia requiring admission27, 28—are too rare to study in a single-ED pediatric population, with 88 and 89,338 cases nationwide, respectively.29

The Institute of Medicine and the Robert Wood Johnson Foundation have identified the effect of ED crowding on children as a research priority.30, 31 Our investigation addresses this priority by modeling the crowding-quality association in an ED population of children with acute asthma exacerbations. We address the scarcity of applicable quality measures through developing and testing several measures across 4 Institute of Medicine dimensions of quality.

We selected acute asthma as the disease model for this study based on the prevalence of the condition, the clinical importance of timely care, and the existence of applicable clinical practice guidelines: the National Asthma Education and Prevention Program.32 Asthma is among the most common reasons children seek ED care, resulting in 750,000 ED visits annually nationwide.33

The objective of this study was to measure the association of the quality between ED crowding and the quality of asthma care for children. We explored this objective in 4 of the 6 dimensions of quality: safety, effectiveness, timeliness, and equity. Our secondary objective was to measure the dose-response effect of ED crowding on quality by comparing quality among crowding percentiles.

Section snippets

Study Design

We performed a cross-sectional study with data collection by retrospective extraction from an electronic medical record of patients aged 2 to 21 years treated for acute asthma in the study ED from November 1, 2007, to October 31, 2008. To preserve the independence of observations, we included each patient's first visit during the study period.

Setting

Study variables were extracted from the electronic medical record of a tertiary care pediatric ED located in an academic children's hospital. The ED has

Characteristics of Study Subjects

During the 12-month study period, the ED registered 56,900 patients; of these, 927 patients met inclusion criteria, all of whom were included. Patient characteristics are shown in Table 2. Preferred language was Spanish for 124 (13.4%) patients; 5 had missing language and were classified as having non-English preference. Ninety-eight (10.6%) patients had no insurance, 531 (57.3%) had public insurance, and 107 (11.5%) had no primary care provider. Of the 927 patients, 248 (26.8%) were admitted

Limitations

A primary limitation of this study is that it was performed at one ED, affecting the generalizability of findings. A second limitation is that the electronic medical record's active patient tracking system may have resulted in discrepancies between the electronic medical record event time and the actual event time. It is likely that this discrepancy is present more often when the ED is crowded, leading to overestimation of the association between crowding and delay of care. It is less likely

Discussion

We demonstrate an association between ED crowding and the quality of the delivery of asthma care in a large, academic ED. We found that crowding exerts a “dose-related” effect on the 3 processes used to measure the timeliness and effectiveness of ED asthma care and can increase the risk of lower-quality care by a factor of 3.8 for 1-hour steroid administration and 1.2 for receipt of indicated asthma score, according to interquartile risk ratio. These findings were robust in multivariable

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    Please see page 192 for the Editor's Capsule Summary of this article.

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    Supervising editor: Kathy N. Shaw, MD, MSCE

    Author contributions: MRS, DF, and MGK conceived the study, designed the analytic plan, and obtained research funding. DR performed data extraction, data quality control, and database management. DF provided statistical advice on study design and analyzed the data. MRS drafted the article, and all authors contributed substantially to its revision. MRS 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. Drs. Sills and Fairclough and Ms. Ranade received support from the Agency for Healthcare Research and Quality (5R03HS016418), the American Lung Association (SB-35832-N), and the Emergency Medicine Foundation.

    Reprints not available from the authors.

    Publication date: Available online October 29, 2010.

    Earn CME Credit: Continuing Medical Education is available for this article at: http://www.ACEP-EMedHome.com.

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