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Associations between crowding and ten-day mortality among patients allocated lower triage acuity levels without need of acute hospital care on departure from the emergency department
Karolinska institutet.ORCID-id: 0000-0003-1815-799x
Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad.ORCID-id: 0000-0002-3964-196X
Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad. Karolinska institutet.
Vise andre og tillknytning
2019 (engelsk)Inngår i: Annals of Emergency Medicine, ISSN 0196-0644, E-ISSN 1097-6760, Vol. 74, nr 3, s. 345-356Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

STUDY OBJECTIVE: We describe the association between emergency department (ED) crowding and 10-day mortality for patients triaged to lower acuity levels at ED arrival and without need of acute hospital care on ED departure.

METHODS: This was a registry study based on ED visits with all patients aged 18 years or older, with triage acuity levels 3 to 5, and without need of acute hospital care on ED departure during 2009 to 2016 (n=705,699). The sample was divided into patients surviving (n=705,076) or dying (n=623) within 10 days. Variables concerning patient characteristics and measures of ED crowding (mean length of stay and ED occupancy ratio) were extracted from the hospital's electronic health records. ED length of stay per ED visit was estimated by the average length of stay for all patients who presented to the ED during the same day and shift and with the same acuity level. The 10-day mortality after ED discharge was used as the outcome measure. Multivariable logistic regression analyses were conducted.

RESULTS: The 10-day mortality rate was 0.09% (n=623). The event group had larger proportions of patients aged 80 years or older (51.4% versus 7.7%) and triaged with acuity level 3 (63.3% versus 35.6%), and greater comorbidity (age-combined Charlson comorbidity index median interquartile range 6 versus 0). We observed an increased 10-day mortality for patients with a mean ED length of stay greater than or equal to 8 hours versus less than 2 hours (adjusted odds ratio 5.86; 95% confidence interval [CI] 2.15 to 15.94) and for elevated ED occupancy ratio. Adjusted odds ratios for ED occupancy ratio quartiles 2, 3, and 4 versus quartile 1 were 1.48 (95% CI 1.14 to 1.92), 1.63 (95% CI 1.24 to 2.14), and 1.53 (95% CI 1.15 to 2.03), respectively.

CONCLUSION: Patients assigned to lower triage acuity levels when arriving to the ED and without need of acute hospital care on departure from the ED had higher 10-day mortality when the mean ED length of stay exceeded 8 hours and when ED occupancy ratio increased.

sted, utgiver, år, opplag, sider
2019. Vol. 74, nr 3, s. 345-356
HSV kategori
Forskningsprogram
Forskningsprofiler 2009-2020, Hälsa och välfärd
Identifikatorer
URN: urn:nbn:se:du-30483DOI: 10.1016/j.annemergmed.2019.04.012ISI: 000482210700011PubMedID: 31229391Scopus ID: 2-s2.0-85067334196OAI: oai:DiVA.org:du-30483DiVA, id: diva2:1331932
Tilgjengelig fra: 2019-06-27 Laget: 2019-06-27 Sist oppdatert: 2021-11-12bibliografisk kontrollert
Inngår i avhandling
1. Patient safety at emergency departments: challenges with crowding, multitasking and interruptions
Åpne denne publikasjonen i ny fane eller vindu >>Patient safety at emergency departments: challenges with crowding, multitasking and interruptions
2018 (engelsk)Doktoravhandling, med artikler (Annet vitenskapelig)
Abstract [en]

Several challenges with patient safety in the emergency department (ED) context have beenpreviously identified, and some commonly mentioned are crowding, multitasking, andinterruptions. The ED is a complex, high-risk work environment where multiple clinicians(physicians, registered nurses [RNs], and licensed practical nurses [LPNs]) are constantlyworking in parallel work processes, in an often crowded ED, while conducting tasksinvolving cognitively demanding decision-making processes. ED crowding has for the past20 years been identified as a problem internationally, resulting in extended ED length of stay(LOS) and increased morbidity and mortality for patients. ED crowding is also considered tohave negative effects on the clinicians' workload and work satisfaction.

Both multitasking and interruptions have been identified as risk factors for patient safety byhaving negative effects on a clinician's decision-making processes and thus increasing therisk of forgetting important details and events because of memory overload. However,information has been lacking about what specific work assignments ED clinicians conduct,and thus there is little information about the types of assignments they perform whilemultitasking and being exposed to interruptions. Further, because not all interruptions lead toerrors and because they are not all preventable, a more refined account of interruptions iscalled for. Moreover, it seems that previous studies have not identified which specific factorsinfluence the ED clinicians' perceptions of interruptions. The work environment has beenreferred to as a possible influencing factor, but specific details on the relationship between thework environment and negative effects from interruptions are pending.

The overall aim of the thesis was to describe ED crowding, and its influence on EDclinicians' work processes (activities, multitasking, and interruptions) and patient outcomes,from a patient safety perspective. The thesis addressed six research questions: 1) How has EDcharacteristics, patient case mix and occurrence of ED crowding changed over time? 2) Whatwork activities are performed by ED clinicians? 3) What kind of multitasking situations areclinicians exposed to during ED work? 4) What kind of interruptions are clinicians exposedto during ED work? 5) How do ED clinicians perceive interruptions? 6) Is there anassociation between ED crowding and mortality for stable patients without the need for acutehospital care upon departure from the ED?

The data in the thesis were generated from two data collections: 1) registry data containingpatient characteristics and measures of ED crowding (ED occupancy ratio [EDOR], ED LOS,and patient/clinician ratios) extracted from the patients' electronic health records (paper I andIV) and 2) observations and interviews with ED clinicians (physicians, RNs, and LPNs)(paper II and III). Nonparametric statistics were used in paper I and III, quantitative and qualitative content analysis were used in paper II and III, and multivariate logistic regressionanalysis was used in paper IV.

The main results in the thesis are presented based on Asplin's conceptual model of EDcrowding, from the aspect of input-throughput-output, and how parts of a sub-optimalthroughput influence patient safety through ED clinicians' work processes and patientoutcomes. During 2009 – 2016 there has been a change in patient case mix at the EDs at thestudy hospital, primarily with an increase in unstable patients (input) and a decrease in thenumber of patients admitted to in-hospital care (output). The median for ED LOS over thestudy period increased, and the largest increases occurred among the subgroups of unstablepatients, patients ≥80 years of age, and those admitted to in-hospital care (throughput).Further, an increase in crowding, in terms of median EDOR and median patients per RNratios, was identified, with an increase in EDOR from 0.8 in 2009 to 1.1 in 2016 and anaverage increase of 0.164 patients/RN/year (throughput). The ED clinicians' workassignments consisted of 15 categories of activities, and information exchange was found tobe the most common activity (42.1%). In contrast, the clinicians only spent 9.4% of theiractivities on direct interaction with patients and their families (ED clinicians' workprocesses). The clinicians multitasked during 23% of their total number of performedactivities, and there was an overall interruption rate of 5.1 interruptions per hour. Themajority of the observed multitasking situations and interruptions in the ED clinicians' workoccurred during demanding activities that required focus or concentration (ED clinicians'work processes). Finally, an association was identified between an increase in ED LOS andEDOR and 10-day mortality for stable patients without the need for acute hospital care upondeparture from the ED (patient outcomes).

This thesis illustrates how a sub-optimal throughput, affected by conditions in both the inputand output components, negatively influence the ED clinicians' work processes as well aspatient outcomes.

sted, utgiver, år, opplag, sider
Stockholm: Karolinska Institutet, Dept of Medicine, Solna, 2018
HSV kategori
Identifikatorer
urn:nbn:se:du-35003 (URN)978-91-7549-892-8 (ISBN)
Disputas
2018-12-14, Rolf Luft, L1:00, Anna Steckséns gata 53, Karolinska University Hospital, Solna, 09:00 (engelsk)
Opponent
Veileder
Tilgjengelig fra: 2020-09-18 Laget: 2020-09-18 Sist oppdatert: 2020-09-18bibliografisk kontrollert

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