Saturday, December 1, 2007

Another Reason ER Overcrowding is Wrong...

ED Length of Stay for Non-STEMI Patients: How Long Is Too Long?

Patients boarded in the ED for longer than 8 hours were less likely to receive guideline-recommended therapies and had increased rates of recurrent MI.

Boarding of admitted patients in the emergency department contributes to ED crowding and ambulance diversion and might adversely affect patient care. Researchers used data from a prospective study of 42,780 patients who presented to 550 U.S EDs with non–ST-segment-elevation myocardial infarction to evaluate how ED length of stay is associated with adherence to evidence-based guidelines for acute administration of five medications (aspirin, β-blockers, heparin, glycoprotein IIb/IIIa inhibitors, and clopidogrel) and with in-hospital adverse events (death and recurrent MI).

The mean ED stay was 8.9 hours, and the median stay was 4.3 hours; 45% of patients had short stays (<4 hours), 40% had average stays (4–8 hours), and 15% had long stays (>8 hours). After adjustment for confounders, patients with long stays were significantly less likely than those with short or average stays to receive each of the five medications within 24 hours after presentation; the greatest difference was noted for aspirin (odds ratio, 0.76 compared with short stay and 0.74 compared with average stay). Rates of in-hospital death did not differ among the three groups. However, patients with long stays were significantly more likely to have recurrent in-hospital MI than those with average (but not short) stays (OR, 1.23). Demographic factors associated with long stays were female sex, nonwhite race, and not having HMO or private insurance.

Comment: The issues contributing to ED crowding and ED boarding are complex and symptomatic of an overburdened system. Although this study suffered from significant methodological flaws, it nonetheless adds to the growing body of evidence suggesting that boarding inpatients in the ED is not just uncomfortable for patients and families but also associated with substandard care.

— Richard D. Zane, MD, FAAEM

Published in Journal Watch Emergency Medicine November 30, 2007

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