Effect of emergency department crowding on pneumonia admission care components.

OBJECTIVE: To determine pneumonia admission care components that are most affected by emergency department (ED) crowding. STUDY DESIGN: Secondary analysis of a cross-sectional observational survey. METHODS: The setting was a 29-bed academic ED with 39,000 visits per year and state-mandated ratios of nurses to patients. The patients were ED admissions with pneumonia, January 1, 2004, to June 30, 2005. From ED medical records and databases, we abstracted the times of arrival, room placement, ordering of chest radiograph and when obtained, ordering of blood culture and when obtained, and ordering of antibiotic and when administered. We assessed associations between ED volume at the time of arrival of a patient with pneumonia and component durations using multivariate linear regression. RESULTS: For 407 ED admissions with pneumonia, the median component durations (in minutes) were as follows: 20 for arrival to room placement, 44 for arrival to chest radiograph order, 10 for chest radiograph order to radiograph obtained, 120 for room placement to antibiotic order, 10 for blood culture order to culture obtained, 30 for antibiotic order to antibiotic administered, and 195 for arrival to antibiotic administered. Sixty-one percent of patients received antibiotic within 4 hours. We estimate that for every 10 additional ED patients the time from arrival to ordering of a chest radiograph was prolonged by 14.3 minutes and from ordering of antibiotic to administration by 9.3 minutes. CONCLUSIONS: Despite compliance with mandated ratios of nurses to patients, the time from antibiotic ordering to administration (a nursing task) was prolonged with higher ED volumes, as were throughput measures. Targeting these may expedite treatment under crowded ED conditions.

Effect of emergency department crowding on time to antibiotics in patients admitted with community-acquired pneumonia.

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.