Note that the main drivers of crowding appeared to be intensity of the ED visit, including giving intravenous fluids, doing blood tests or procedures, and giving medications, as well as use of advanced imaging techniques.
Emergency departments are getting more crowded over time, and possibly at a steeper rate than previously thought, researchers found.
Mean occupancy — the number of patients in the emergency department (ED) divided by the number of treatment spaces — rose at an annual rate of 3.1% over an eight-year period, compared with a 1.9% rise per year in ED visits, the metric by which crowding is typically measured, according to Stephen Pitts, MD, MPH, of Emory University in Atlanta, and colleagues.
They reported their findings online in the Annals of Emergency Medicine.
“A relentlessly increasing mean occupancy suggests that these periods of ED crowding are becoming more frequent, widespread, and severe,” they wrote.
The volume of patients treated in U.S. emergency departments has been on the rise, the researchers said, and has been tied to greater crowding in these places.
To look at that growth in terms of changes in mean occupancy, Pitts and colleagues assessed data from the National Hospital Ambulatory Medical Care Survey database from 2001 to 2008.
During that time, they found the number of ED visits increased by 1.9% per year — a rate 60% faster than population growth, which was 1.2% annually.
The mean occupancy, however, grew even more rapidly, at 3.1% per year, or 27% during the overall study period, they found.
“These findings could have ominous implications for patient safety and access to emergency care in the U.S.,” they wrote.
They also found that the average length of an ED visit rose by 2.9% annually.
Among the factors associated with crowding, use of advanced imaging increased most, by 140%, they wrote.
But imaging had a smaller effect on the occupancy trend than practice intensity, which refers to the use of intravenous fluids and blood tests, the performance of any clinical procedure, and the mention of two or more medications, they reported.
Increased intensity of care “is a larger driver of … occupancy than the boarding of admitted patients,” they wrote, referring to the practice by which a patient is held in the ED until a hospital bed is available.
“Ironically, it is possible that innovations intended to speed patients through the ED — such as authorizing the early ordering of blood work and x-rays at triage — may be bogging down patient flow instead,” Pitts said in a statement.
Greater practice intensity may reflect more widespread implementation of financial incentives that reward higher intensity of services, or it may reflect increasing practice of defensive medicine, the researchers said.
Among patient characteristics, having Medicare and being between the ages of 45 to 64 accounted for “small, disproportionate increases in occupancy,” they wrote.
The study was limited because the database lacked specific ED identifiers, which prevented multivariable analysis, the researchers cautioned. Missing data was another limitation, including for length of ED visit, which might not have been random.
However, they said their investigation into mean ED occupancy rate is “probably a better surrogate for ED crowding than the number of visits,” and concluded that ED crowding “is getting worse.”
“A rapidly rising tide of older, sicker patients combined with a an increasingly interventionist practice style is putting enormous pressure on a shrinking supply of emergency departments,” Pitts said in a statement. “This has ominous implications for patient safety and access to emergency care in the U.S.”
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