CEMRC presentation 20091108

Emergency Department Crowding is Associated with Decreased Quality of Care for Children with Acute Asthma

Marion R Sills, MD, MPH

Background

Crowding Quality

Background

Crowding Quality

Background: IOM Dimensions of Quality Six Dimensions of QualitySafe (‘‘avoiding injuries to patients from the care that is intended to help them”)

Effective (“providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit”)

Patient-centered (“providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all decisions”)

Timely (“reducing waits and sometimes harmful delays for both those who receive and those who give care”)

Efficient (“avoiding waste, in particular waste of equipment, supplies, ideas, and energy”)

Equitable (care that ‘‘does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status’’)

Background: IOM Dimensions of Quality

Dimension Quality measures associated with crowdingSafe errors in registrationEffective mortality

non-receipt of analgesia in patients with painPatient-centered

patient satisfaction

Timely time-to-antibiotic for patients with pneumoniatime-to-thrombolysis for patients with AMItime-to-analgesia in patients with paintransport delayspatients leaving without being seen

Efficient inpatient LOSED revisits by ED patients and by discharged inpatients

Equitable EDs located in poorer neighborhoodsEDs used disproportionately by uninsured persons

Background: Dimensions in our DataDimension Quality measuresSafe Transfer to ICU < 24 hr after ED admissionEffective Receipt of asthma score

Receipt of beta-agonist Receipt of steroid % of CXR that are negative

Patient-centered

No measures

Timely Time to asthma score < 1 hr Time to beta-agonist < 1 hr Time to steroid < 1 hr LWBS

Efficient Return to ED within 72 hours of 1st visit for asthmaEquitable Include insurer, PCP, and preferred language variable

in models of other dimensions

Background

Crowding Quality

Background

Crowding Quality

Background

Crowding Quality

•Complexity:Multi-factorial scalesSimple measures

•Validated againstSubjective rating of crowdingQuality of care

Background

• Simple: ED Occupancy =

• Multi-factorial: NEDOCS =

ED patientsED beds

Background

Crowding Quality

•Complexity:Multi-factorial scalesSimple measures

•Validated againstSubjective rating of crowdingQuality of care

Objective 1

Crowding Timeliness

• Determine which of several simple indicators of ED crowding are most predictive of untimely care

Objective 2

Crowding Quality

• Use the selected crowding measures to explore timeliness and other quality dimensions in ED asthma care for children

Questions

• Objective 1 already submitted as manuscript• Objective 2:

Enough for additional manuscript? Include all the extra measures we intended to

model but could not?

Objective 1

Crowding Timeliness

• Determine which of several simple indicators of ED crowding are most predictive of delayed care

Methods: Patient Population

• Retrospective cohort• EMR-derived• All ED patients with asthma as first diagnosis (end-of-visit case-definition)

• Age 2-21 years• 12 month study period

Full asthma study population

Methods: Selection of Crowding Measures

Crowding measures Process measures

9 measures of crowding

Timeliness of 3 processes

Asthma scoreInhaled beta-agonistSystemic corticosteroid






Derived from prior literature

Global measures Total patient-care hoursED occupancyInput measures Number waiting to see attendingNumber arriving in 6 hoursThroughput measuresMean ED LOS of patients dischargedMean ED LOS for patients admittedOutput measuresNumber discharged in 6 hoursNumber admitted in 6 hoursHospital occupancy


Global measures Total patient-care hours (sum of ED LOS for all patients in ED)

ED occupancy (ratio: # ED patients / # ED beds)

Input measures Number waiting to see attending (# ED patients not yet assigned to billing provider)

Number arriving in 6 hours (# newly registered patients in prior 6 hours)

Throughput measuresMean ED LOS of patients discharged (mean ED LOS for patients discharged from

the ED in prior 6 hours)

Mean ED LOS for patients admitted (mean ED LOS for patients transferred to inpatient beds in prior 6 hours)

Output measuresNumber discharged in 6 hours (# patients discharged from ED in prior 6 hours)

Number admitted in 6 hours (# patients transferred to inpatient beds in prior 6 hours)

Hospital occupancy (% occupancy of whole hospital)


Methods: Selection of Process Measures





Defined relevant subgroups based on•NHLBI guideline

•literature

Methods

Full asthma study population

Asthma score indicated subgroup

Beta-agonistindicated subgroup

Steroid indicated subgroup

Initial asthma score > 7

Received > 2 beta-agonist

treatments*

Received asthma medication

in ED

*excluded those with pre-hospital steroid recorded

Methods

Other patient characteristics were included based on previous studies

Severity indicatorsDemographic variables History elements Access-related variables

Methods: Analysis

• Summary statistics • Adjusted risk of each quality measure at 5 percentiles of crowding for each crowding measure

• Significance of the change in adjusted risk when moving between crowding percentiles

Demographics Age in years [median (IQR)] 6 (3, 9)Preferred language English [n (%)] 798 (86.1)Public insurance [n (%)] 531 (57.3)Initial History Information Has PCP [n (%)] 820 (88.5)Second hand smoke in home [n (%)] 185 (20.0)Severity Indicators Initial pulse-oximetry < 90% [n (%)] 179 (19.3)Triage level 1 or 2 (most severe) [n (%)] 325 (35.1)Ambulance arrival [n (%)] 121 (13.1)

Results: Selected Patient Characteristics

n = 927

Results: Subgroups and Associated Process Measures

Subgroup Asthma-score indicated subgroup (n = 832)

Beta-agonist indicated subgroup (n = 551)

Steroid indicated subgroup (n = 640)

Received indicated process [n (%)]

694 (83)

551 (100)

556 (87)

Received indicated process in ≤ 1 hour [n (% of process-receivers)]

375 (54)

355 (64)

130 (23)

Time to process, minutes [median (IQR)]

53 (29, 90)

45 (27, 76)

99 (63, 154)

Results: Median Values (10th, 25th, 75th, and 90th percentiles) of Crowding Measures

Total patient-care hours 125 (58, 85, 180, 254)ED occupancy 47 (19, 32, 68, 85)Number waiting to see attending 6 (2, 3, 11, 17)Number arriving in 6 hours 44 (16, 26, 58, 67)Mean ED LOS of patients discharged (minutes) 186 (135, 159, 225, 279)

Mean ED LOS for patients admitted (minutes) 348 (122, 248, 538, 818)

Number discharged in 6 hours 39 (15, 23, 53, 63)Number admitted in 6 hours 3 (1, 2, 5, 7)Hospital occupancy 75 (67, 70, 81, 85)

ED Occupancy

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Results: Adjusted Risk for Steroid Receipt in One Hour by Crowding Measure Percentile

Crowding Measure

Pro

cess

Mea

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Crowding Measure

Pro

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Mea

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Mean LOS of Discharged Patients (ln)

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Results: Adjusted Risk for Asthma Score Receipt in One Hour by Crowding Measure Percentile


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Number Waiting for Attending (ln)

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Mean LOS of Admitted Patients (ln)

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ED Arrivals in 6 hrs

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ED Occupancy

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Admitted in 6 hr

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Discharged in 6 hr

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Hospital Occupancy

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Total Patient-Care Hours (sqrt)

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Results: Adjusted Risk for Beta-Agonist Receipt in One Hour by Crowding Measure Percentile


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ED Occupancy

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ED Arrivals in 6 hrs

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Admitted in 6 hr

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Discharged in 6 hr

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Hospital Occupancy

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Hospital Occupancy

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Admitted in 6 Hours

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Discharged in 6 Hours

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Number Waiting for Attending

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ED Arrivals in 6 Hours

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Admitted in 6 Hours

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Results: Relative Risk Comparing the 10th and 90th Percentiles of Crowding for the Three Selected Crowding Measures

Subgroup Asthma-score indicated subgroup

Beta-agonist indicated subgroup

Steroid indicated subgroup

Process►

Crowding Measure▼

Received asthma score in 1st hour

Received beta-agonist in 1st hour

Received steroid in 1st hour

ED Occupancy 3.21 2.23 7.80Number Waiting for Attending

2.83 1.95 5.83

Total Patient-care Hours

2.24 1.80 5.17


Hospital Occupancy

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Admitted in 6 Hours

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Results: ED Occupancy and Number Waiting for Attending


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ED Occupancy

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ED Occupancy

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ED Occupancy

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Steroid < 1 Hr

Beta-Agonist < 1 Hr

Asthma Score < 1 Hr

Discussion

• A significant proportion had delayed receipt of an indicated process

• The greatest delay was in steroid delivery

Asthma-score

Beta-agonist

Steroid

Time to process, minutes [median (IQR)]

53 (29, 90)

45 (27, 76)

99 (63, 154)

Discussion

• Crowding exerts a “dose-related” effect on timeliness

• Crowding can change the probability of delayed care by 7-fold

Process►

Crowding Measure▼

Received asthma score in 1st hour

Received beta-agonist in 1st hour

Received steroid in 1st hour

ED Occupancy 3.21 2.23 7.80Number Waiting for Attending

2.83 1.95 5.83


2.24 1.80 5.17

Discussion

• Key measures of crowding include ED occupancynumber waiting for attending total patient-care hours

• 2 global measures and 1 input measure• Differs from adult-population ED literature: output measures of crowding are most related to quality

Objective 1

Crowding Timeliness

• Determine which of several simple indicators of ED crowding are most predictive of delayed care

ED occupancynumber waiting for attending total patient-care hours

Objective 2

Crowding Quality

• Use the selected crowding measures to explore more quality domains in ED asthma care for children

Methods

Crowding measures Quality measures

•ED occupancy•number waiting for attending•total patient-care hours

•5 dimensions*

Conceptual Model

*no EMR measures of patient-centeredness

Methods: Quality MeasuresDimension Quality measuresSafe Transfer to ICU < 24 hr after ED admissionEffective Receipt of asthma score

Receipt of beta-agonist Receipt of steroid % of CXR that are negative

Timely Time to asthma score < 1 hr Time to beta-agonist < 1 hr Time to steroid < 1 hr LWBS

Efficient Return to ED within 72 hours of 1st visit for asthmaEquitable Include insurer, PCP, and preferred language variable

in models of other dimensions

Methods: Analysis

• Summary statistics • For safety, effectiveness, timeliness and efficiency quality measures:

Adjusted risk of each quality measure at 5 percentiles of crowding for each crowding measure

Significance of the change in adjusted risk when moving between crowding percentiles

Methods: Analysis

• For equity quality measuresTest association with effectiveness and

timeliness measuresTest whether they are moderators of the

crowding-quality models involving other quality measures


Conceptual Model

Equity measures

Moderators? Explanatory variables?

Demographics Age in years [median (IQR)] 6 (3, 9)Preferred language English [n (%)] 798 (86.1)Public insurance [n (%)] 531 (57.3)Initial History Information Has PCP [n (%)] 820 (88.5)Second hand smoke in home [n (%)] 185 (20.0)Severity Indicators Initial pulse-oximetry < 90% [n (%)] 179 (19.3)Triage level 1 or 2 (most severe) [n (%)] 325 (35.1)Ambulance arrival [n (%)] 121 (13.1)

Results: Selected Patient Characteristics

n = 927

Results: Eliminated Quality Measures

Several quality measures had insufficient #s for analysis

Results: Eliminated Quality MeasuresDimen-sion

Quality measures n (%)

Safe Transfer to ICU < 24 hr after ED admission 0 (0%)*Effective Receipt of asthma score

Receipt of beta-agonist 551 (100)Receipt of steroid % of CXR that are negative 205 (89)†

Timely Time to asthma score < 1 hr

Time to beta-agonist < 1 hr

Time to steroid < 1 hr

LWBS 2 (0.2%)Efficient Return to ED within 72 hours of 1st visit 24 (4%)*Equitable Include insurer, PCP, and preferred language

variable in models of other dimensions

*denominator = admitted patients (n = 653)†denominator = discharged patients (n = 231)

Background: Dimensions in our DataDimension Quality measures n (%)Effective Receipt of asthma score 694 (83)

Receipt of steroid 556 (87)Timely Time to asthma score < 1 hr 375 (45)

Time to beta-agonist < 1 hr 355 (64)Time to steroid < 1 hr 130 (20)

Equitable Preferred language English 798 (86)

Has PCP 820 (89)

No insurance 98 (11)

Public insurance 531 (57)

Background: Dimensions in our DataDimension Quality measures n (%)Effective Receipt of asthma score 694 (83)

Receipt of steroid 556 (87)Timely Time to asthma score < 1 hr 375 (45)

Time to beta-agonist < 1 hr 355 (64)Time to steroid < 1 hr 130 (20)

Equitable Preferred language English 798 (86)

Has PCP 820 (89)

No insurance 98 (11)

Public insurance 531 (57)

New analyses in Objective 2


•ED occupancy•Number waiting for attending•Total patient-care hours

•Receipt of Asthma scoreSteroid

•Receipt < 1 hr ofAsthma scoreBeta-agonistSteroid

Conceptual Model

Moderators (Equity measures)•Preferred language English •Has PCP•No insurance •Public insurance





Conceptual Model


ResultsAsthma Score

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Risk 10%tile Risk 25%tile Risk 50%tile Risk 75%tile Risk 90%tile

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Total Hours X Receipt

ED Occupancy X Receipt

Number Waiting for Provider XReceipt

Total Hours X Timely Receipt

ED Occupancy X Timely Receipt

Number Waiting for Provider XTimely Receipt

effectiveness

timeliness

ResultsBeta Agonist

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ED Occupancy X TimelyReceipt


timeliness

ResultsSteroid

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Number Waiting for ProviderX Receipt

Total Hours X TimelyReceipt


Number Waiting for ProviderX Timely Receipt

effectiveness

timeliness

Results: Relative Risk Comparing the 10th and 90th Percentiles of Crowding

Process►

Crowding Measure▼

Received asthma score

Received steroid

Asthma score in 1st hour

Beta-agonist in 1st hour

Steroid in 1st hour

ED Occupancy 1.22 1.12 3.21 2.23 7.80Number Waiting for Attending

1.18 1.16 2.83 1.95 5.83


1.12 1.05* 2.24 1.80 5.17

*not statistically significant





Results


No significant effect as moderators

No significant association with effectiveness or timeliness

Conclusions

• High rates of receipt of indicated processes (effectiveness)

• Lower rates of timely receipt (timeliness)

Asthma Score

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Number Waiting for Provider XReceipt


ED Occupancy X Timely Receipt


Steroid

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Number Waiting for ProviderX Receipt

Total Hours X TimelyReceipt


Number Waiting for ProviderX Timely Receipt

Conclusions

Process►

Crowding Measure▼

Received asthma score

Received steroid

Asthma score in 1st hour

Beta-agonist in 1st hour

Steroid in 1st hour

ED Occupancy 1.22 1.12 3.21 2.23 7.80Number Waiting for Attending

1.18 1.16 2.83 1.95 5.83


1.12 NS 2.24 1.80 5.17

• Crowding had larger magnitude association with timeliness measures than with effectiveness (receipt/non-receipt) measures

Conclusions

• Equity measures (language, PCP, insurance)

Are not associated with either effectiveness or timeliness of care

Do not moderate the association between crowding and either effectiveness or timeliness of care

Questions

• Objective 1 already submitted as manuscript• Objective 2:

Enough for additional manuscript? Include all the extra measures we intended to

model but could not?Other feedback

Healthcare

CEMRC presentation 20091108