The impact of emergency department crowding measures on time to antibiotics for patients with community-acquired pneumonia.

STUDY OBJECTIVE We seek to determine the impact of emergency department (ED) crowding on delays in antibiotic administration for patients with community-acquired pneumonia. METHODS We performed a retrospective cohort study of adult patients admitted with community-acquired pneumonia from January 1, 2003, to April 31, 2005, at a single, urban academic ED. The main outcome was a delay (>4 hours from arrival) or nonreceipt of antibiotics in the ED. Eight ED crowding measures were assigned at triage. Multivariable regression and bootstrapping were used to test the adjusted impact of ED crowding measures of delayed (or no) antibiotics. Predicted probabilities were then calculated to assess the magnitude of the impact of ED crowding on the probability of delayed (or no) antibiotics. RESULTS In 694 patients, 44% (95% confidence interval [CI] 40% to 48%) received antibiotics within 4 hours and 92% (95% CI 90% to 94%) received antibiotics in the ED. Increasing levels of ED crowding were associated with delayed (or no) antibiotics, including waiting room number (odds ratio [OR] 1.05 for each additional waiting room patient [95% CI 1.01 to 1.10]) and recent ED length of stay for admitted patients (OR 1.14 for each additional hour [95% CI 1.04 to 1.25]). When the waiting room and recent length of stay were both at the lowest quartiles (ie, not crowded), the predicted probability of delayed (or no) antibiotics within 4 hours was 31% (95% CI 21% to 42%); when both were at the highest quartiles, the predicted probability was 72% (95% CI 61% to 81%). CONCLUSION ED crowding is associated with delayed and nonreceipt of antibiotics in the ED for patients admitted with community-acquired pneumonia.

[1]  M. Fine,et al.  A prediction rule to identify low-risk patients with community-acquired pneumonia. , 1997, The New England journal of medicine.

[2]  B. Brodie,et al.  Importance of time to reperfusion for 30-day and late survival and recovery of left ventricular function after primary angioplasty for acute myocardial infarction. , 1998, Journal of the American College of Cardiology.

[3]  J. Twanmoh,et al.  When overcrowding paralyzes an emergency department. , 2006, Managed care.

[4]  A. Kellermann,et al.  Critical decision making: managing the emergency department in an overcrowded hospital. , 1991, Annals of emergency medicine.

[5]  A Russell Localio,et al.  The association between emergency department crowding and hospital performance on antibiotic timing for pneumonia and percutaneous intervention for myocardial infarction. , 2006, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[6]  J. Steiner,et al.  Chart reviews in emergency medicine research: Where are the methods? , 1996, Annals of emergency medicine.

[7]  Robert L Wears,et al.  The quality gap: searching for the consequences of emergency department crowding. , 2004, Annals of emergency medicine.

[8]  George Wells,et al.  The effect of hospital occupancy on emergency department length of stay and patient disposition. , 2003, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[9]  M. Fine,et al.  Quality of care, process, and outcomes in elderly patients with pneumonia. , 1997, JAMA.

[10]  Profiles in patient safety: Antibiotic timing in pneumonia and pay-for-performance. , 2006, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[11]  M. Ardagh,et al.  Emergency department overcrowding: the Emergency Department Cardiac Analogy Model (EDCAM). , 2005, Accident and emergency nursing.

[12]  J. Bartlett,et al.  Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumonia. , 2004, Archives of internal medicine.

[13]  C. Begley,et al.  Emergency Room Use and Access to Primary Care: Evidence from Houston, Texas , 2006, Journal of health care for the poor and underserved.

[14]  Mohamud Daya,et al.  Effect of increased ICU capacity on emergency department length of stay and ambulance diversion. , 2005, Annals of emergency medicine.

[15]  Karin V Rhodes,et al.  A conceptual model of emergency department crowding. , 2003, Annals of emergency medicine.

[16]  S. Piantadosi,et al.  The ecological fallacy. , 1988, American journal of epidemiology.

[17]  M. Fine,et al.  Influence of age on symptoms at presentation in patients with community-acquired pneumonia. , 1997, Archives of internal medicine.

[18]  R. Wunderink,et al.  Delayed administration of antibiotics and atypical presentation in community-acquired pneumonia. , 2006, Chest.

[19]  R. Derlet,et al.  Overcrowding in emergency departments: increased demand and decreased capacity. , 2002, Annals of emergency medicine.

[20]  P. Sprivulis,et al.  Access block causes emergency department overcrowding and ambulance diversion in Perth, Western Australia , 2005, Emergency Medicine Journal.

[21]  Shari J. Welch,et al.  An independent evaluation of four quantitative emergency department crowding scales. , 2006, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[22]  J. Hollander,et al.  Systematic Delays in Antibiotic Administration in the Emergency Department for Adult Patients Admitted with Pneumonia , 2006 .

[23]  D. Lowe,et al.  Clotting competence of intracavitary blood in trauma victims. , 1981, Annals of emergency medicine.

[24]  D. Magid,et al.  Emergency department crowding: consensus development of potential measures. , 2003, Annals of emergency medicine.

[25]  N. Rathlev,et al.  Time series analysis of variables associated with daily mean emergency department length of stay. , 2007, Annals of emergency medicine.

[26]  J. Schumacher.  Emergency medicine and older adults: continuing challenges and opportunities. , 2005, The American journal of emergency medicine.

[27]  R. Niska,et al.  National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary. , 2008, National health statistics reports.

[28]  R. Kravitz,et al.  Frequent overcrowding in U.S. emergency departments. , 2001, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[29]  B. Carlin,et al.  Insurance status and access to urgent ambulatory care follow-up appointments. , 2005, JAMA.

[30]  Jerod M. Loeb,et al.  Quality of Care in U.S. Hospitals as Reflected by Standardized Measures, 2002-2004 , 2005 .

[31]  R. Vogel,et al.  Emergency department use by nursing home residents. , 1998, Annals of emergency medicine.

[32]  J. Richards,et al.  Overcrowding in the nation's emergency departments: complex causes and disturbing effects. , 2000, Annals of emergency medicine.