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Emergency department crowding negatively influences outcomes for children presenting with asthma: a population-based retrospective cohort study

Abstract

Background

Emergency department (ED) crowding may delay assessment and management and compromise outcomes. The association between the crowding metric time to physician initial assessment (PIA) and outcomes for children presenting for acute asthma is examined.

Methods

A population-based retrospective cohort of all presentations to 18 high-volume EDs during 2010–2014 in Alberta, Canada was created. Hourly, facility-specific median PIAs were calculated. Physician claims and hospitalizations data were linked for children (2–17 years) presenting for asthma.

Results

Twenty-five thousand three hundred and eighty-three presentations (16,053 children) were made for asthma. Crowding was common in all hospitals and affected PIA more for lower acuity presentations. For every 1-h increase in median facility PIA, the individual-level PIA increased by 13 min (95% CI: 12, 14) for high, 43 min (95% CI: 42, 44) for moderate, and 60 min (95% CI: 58, 61) for the low acuity groups, when adjusted by predictors. Similarly, length of stay increased by 6, 36, and 45 min for the high, moderate, and low acuity groups, respectively. Increased PIA resulted in more departures prior to completion of care for the lower acuity groups.

Conclusions

Crowding adversely affects short-term outcomes of less ill children more than those who are more ill. When EDs experience increased crowding, care to patients with asthma is delayed; effective strategies to reduce crowding and delays to care are urgently needed.

Impact

  • For children presenting to EDs for asthma, increased time to physician initial assessment adversely affects short-term outcomes of patients with less severe presentations to a greater extent compared to those who are most severe.

  • Times to physician initial assessment are below recommended benchmarks; however, delays in care exist that impact LOS, odds of admission, and premature patient departures.

  • Pediatric patients with severe asthma are seen quickly and their outcomes are excellent.

  • Since crowding adversely affects short-term outcomes of pediatric patients with asthma, efforts to reduce ED crowding and assess patients with asthma in a more timely manner are needed.

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Fig. 1: Percent of children (aged 2–17) years presenting foor asthma and any condition by Canadian Triage and Acuity Scale (CTAS) groups.
Fig. 2: Coefficient estimates (with 95% confidence intervals) for ED crowding metric time to physician initial assessment (PIA) for each continuous outcome and each Canadian Triage and Acuity Scale (CTAS) group.

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Acknowledgements

The authors thank Meng Lin of the Alberta SPOR data platform and AHS Research Data Services for providing health datasets. The authors also thank Jeffrey Bachman, MSc for accessing and preparing the Statistics Canada data and Larry Laliberte at the University of Alberta for providing the Statistics Canada data. This study was partially supported by summer student research awards to S.S. by Alberta Innovates-Health Solutions and the Women & Children’s Health Research Institute. This research has been funded by the generous support of the Stollery Children’s Hospital Foundation through the Women and Children’s Health Research Institute. This study was also supported by a grant from Alberta Health (AHW FP12-784). At the time of this project, B.H.R. was supported by Tier I Canada Research Chair in Evidence-based Emergency Medicine from the Canadian Institutes of Health Research (CIHR; Ottawa, Canada). The funding sources had no direct involvement in the study design, analysis, interpretation, or decision to submit this work.

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S.S. obtained summer student funding, performed initial analyses, provided an initial draft of the manuscript, and critically reviewed the manuscript for important intellectual content. B.H.R. conceptualized and designed the study, obtained funding, interpreted results, and reviewed and revised the manuscript. M.B.O. contributed to study conceptualization, results interpretation, manuscript writing, and critically reviewed the manuscript for important intellectual content. R.J.R. conceptualized and designed the study, coordinated and supervised data extraction, obtained summer student funding, directed statistical analyses, performed modeling analyses, interpreted results, and reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Corresponding author

Correspondence to Rhonda J. Rosychuk.

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Competing interests

B.H.R. received salary support from the Canadian Institutes of Health Research (CIHR; Ottawa, Canada). M.B.O., B.H.R., and R.J.R. are employees of the University of Alberta. The authors have no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years and no other relationship or activities that could appear to have influenced the submitted work. The authors have no financial relationships relevant to this article to disclose.

Ethics

The Health Research Ethics Board of the University of Alberta (Pro00056282) approved this study and patient consent was not required.

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Sagaidak, S., Rowe, B.H., Ospina, M.B. et al. Emergency department crowding negatively influences outcomes for children presenting with asthma: a population-based retrospective cohort study. Pediatr Res 89, 679–685 (2021). https://doi.org/10.1038/s41390-020-0918-2

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