Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.
Ann Emerg Med. 2011 Mar;57(3):191-200.e1-7. doi: 10.1016/j.annemergmed.2010.08.027.
We seek to determine which dimensions of quality of care are most influenced by emergency department (ED) crowding for patients with acute asthma exacerbations.
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.
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).
ED crowding is associated with decreased timeliness and effectiveness-but not equity-of care for children with acute asthma.
我们旨在确定哪些医疗护理质量维度受急诊（ED）拥挤对急性哮喘加重患者的影响最大。
本横断面研究采用回顾性数据收集，纳入了 2007 年 11 月至 2008 年 10 月在一家儿童医院 ED 接受急性哮喘治疗的 2 至 21 岁患者。我们研究了 3 个护理流程 - 哮喘评分、β-激动剂和皮质类固醇的使用 - 以及 9 个代表 3 个质量维度的质量指标：及时性（每个流程的 1 小时内接收）、有效性（每个流程的接收/未接收）和公平性（语言、确定的初级保健提供者和保险）。两个主要的独立变量是 ED 占有率和等待看主治医生的人数。模型根据年龄、语言、保险、初级保健途径、分诊级别、救护车到达、血氧饱和度、吸烟暴露和时间进行调整。对于及时性和有效性质量指标，我们计算了在每个拥挤指标的 5 个百分位数下每个质量指标的调整风险，并评估了调整后的相对四分位风险比的显著性。对于公平性措施，我们测试了它们作为拥挤-质量模型的调节因素的作用。
哮喘人群包括 927 名患者。及时性和有效性质量指标与拥挤呈负相关，呈剂量相关，公平性措施并未调节这种相关性。与拥挤指标处于第 25 百分位相比，当每个拥挤指标处于第 75 百分位时，患者接受及时护理的可能性降低了 52%至 74%，接受有效护理的可能性降低了 9%至 14%（P<.05）。
ED 拥挤与儿童急性哮喘的护理及时性和有效性降低有关，但与公平性无关。
