Department of Emergency Medicine, Department of Health Policy, George Washington University School of Medicine, Washington, DC, USA.
Acad Emerg Med. 2010 Aug;17(8):834-9. doi: 10.1111/j.1553-2712.2010.00780.x.
This study sought to determine if emergency department (ED) crowding was associated with longer ED length of stay (LOS) and time to ordering medications (nebulizers and steroids) in patients treated and discharged with acute asthma and to study how delays in ordering may affect the relationship between ED crowding and ED LOS.
A retrospective cohort study was performed in adult ED patients aged 18 years and older with a primary International Classification of Diseases, 9th Revision (ICD-9), diagnosis of asthma who were treated and discharged from two EDs from January 1, 2007, to January 1, 2009. Four validated measures of ED crowding (ED occupancy, waiting patients, admitted patients, and patient-hours) were assigned at the time of triage. The associations between the level of ED crowding and overall LOS and time to treatment orders were tested by analyzing trends across crowding quartiles, testing differences between the highest and lowest quartiles using Hodges-Lehmann distances, and using relative risk (RR) regression for multivariable analysis.
A total of 1,716 patients were discharged with asthma over the study period (932 at the academic site and 734 at the community site). LOS was longer at the academic site than the community site for asthma patients by 90 minutes (95% confidence interval [CI] = 79 to 101 minutes). All four measures of ED crowding were associated with longer LOS and time to treatment order at both sites (p < 0.001). At the highest level of ED occupancy, patients spent 75 minutes (95% CI = 58 to 93 minutes) longer in the ED compared to the lowest quartile of ED occupancy. In addition, comparing the highest and lowest quartiles of ED occupancy, time to nebulizer order was 6 minutes longer (95% CI = 1 to 13 minutes), and time to steroid order was 16 minutes longer (95% CI = 0 to 38 minutes). In the multivariable analysis, the association between ED crowding and LOS remained significant. Delays in nebulizer and steroid orders explained some, but not all, of the relationship between ED crowding and ED LOS.
Emergency department crowding is associated with longer ED LOS (by more than 1 hour) in patients who ultimately get discharged with asthma flares. Some but not all of longer LOS during crowded times is explained by delays in ordering asthma medications.
本研究旨在确定急诊（ED）拥挤是否与急性哮喘患者接受治疗和出院后的 ED 停留时间（LOS）和用药（雾化器和类固醇）时间延长有关，并研究用药延迟如何影响 ED 拥挤与 ED LOS 之间的关系。
本研究为回顾性队列研究，纳入 2007 年 1 月 1 日至 2009 年 1 月 1 日期间，在两家 ED 接受治疗和出院的年龄在 18 岁及以上、主要诊断为哮喘的成年患者。在分诊时，将四个经过验证的 ED 拥挤度指标（ED 占用率、待诊患者数、收治患者数和患者小时数）进行赋值。通过分析拥挤度四分位数的趋势、比较最高和最低四分位数的 Hodges-Lehmann 差异，以及使用相对风险（RR）回归进行多变量分析，检验 ED 拥挤度水平与整体 LOS 和治疗医嘱下达时间之间的关联。
研究期间，共有 1716 例哮喘患者出院（学术中心 932 例，社区中心 784 例）。与社区中心相比，学术中心哮喘患者的 LOS 延长了 90 分钟（95%置信区间[CI]为 79 至 101 分钟）。所有四个 ED 拥挤度指标在两个站点均与 LOS 延长和治疗医嘱下达时间延长相关（p < 0.001）。在 ED 占用率最高的情况下，患者在 ED 停留的时间比 ED 占用率最低的患者长 75 分钟（95%CI=58 至 93 分钟）。此外，比较 ED 占用率最高和最低四分位数，雾化器医嘱下达时间延长 6 分钟（95%CI=1 至 13 分钟），类固醇医嘱下达时间延长 16 分钟（95%CI=0 至 38 分钟）。在多变量分析中，ED 拥挤与 LOS 之间的关联仍然显著。雾化器和类固醇医嘱的延迟解释了 ED 拥挤与 ED LOS 之间部分关系，但并非全部关系。
在最终因哮喘发作出院的患者中，ED 拥挤与 ED LOS 延长（超过 1 小时）有关。在拥挤时段 LOS 延长的部分原因是雾化器和类固醇等哮喘药物的医嘱下达延迟。
